High yield Flashcards

Question

what treatments are available for pre op anaemia

Answer 1

oral iron IV iron EPO stimulating agents blood transfusion

Answer 2

- A clinical concept with the goal of avoiding unnecessary blood transfusions to improve patient outcomes and safety. - Also saves the hospital resources by lowering transfusion rates Involves 3 pillars: - early detection and treatment of preoperative anaemia - minimising periop blood loss - improving tolerance to anaemia in the post op setting these can be implemented pre op, intra op and post op

Answer 3

- Pilar 1: detecting and minimising anaemia o FBC 4-6 weeks before for all major elective surgery o If anaemic also do haematinics o Oral iron therapy or IV iron o Recheck FBC to check treatment worked - Pilar 2 – minimising blood loss o Identify bleeding risk – PMH, FHx, type of surgery o Review medications – antiplatelets/ coagulation o Procedure planning to minimise blood loss - Pillar 3 – improving tolerance of post op anaemis o Assess and optimise physiological reserve – pulmonary and cardiac function

Answer 4

- Pilar 1: detecting and minimising anaemia o Proceed only when red cell mass optimised - Pilar 2 – minimising blood loss o Surgical techniques – laparoscopic, robotic o Regional anaesthesia o Hypotensive anaesthesia in some cases o Physiology to promote optimal coagulation – normothermia, calcium >1mM , pH >7.2 o TXA – if blood loss >500ml o Cell salvage if blood loss >1L o Point of care testing – ROTEM and Haemcue o Neuroaxial blockage – evidence that this is blood sparing in ortho - Pillar 3 – improving tolerance of post op anaemis o Optimise physiology – cardiac output , oxygenation

Answer 5

- Pilar 1: detecting and minimising anaemia o Manage nutrition , may need IV iron - Pilar 2 – minimising blood loss o Monitor for bleeding and manage prompty o Autologous cell salvage – drains o Good coagulation – normothermia, Ca o Reduce iatrogenic blood loss – blood sampling - Pillar 3 – improving tolerance of post op anaemia o Optimise physiology – cardiac output , oxygenation, may need vasopressors to support organ perfusion o Minimise oxygen consumption – warming , avoid/ treat infections promptly , good analgesia to reduce sympathetic activation o Restrictive transfusion threshold – 70 g/l / 80 in CVS disease

Answer 6

- Check the blood against the compatibility label – should both have the same 14 digit number - Check you have the right patient on wrist band and check this matches the info on the blood – first name, last name, DoB, hospital number - Expiry date on blood - Visual check for damage of the bag, discolouration, clots

Answer 7

- Increased cardiac output – sympathetic response to hypoxia plus less viscous blood - Increased 2,3 DPG - Right shift of O2 dissociation curve to help unload - Increased ventilation - Increased oxygen extraction by tissues - Redistribution of blood to vital organs – heart and brain

Answer 8

- Low ferritin - Low transferrin saturation - High total iron binding capacity - Low reticulocyte count

Answer 9

High ferritin - Low transferrin saturation - Markers such as CRP may also be raised due to relationship with inflammation

Answer 10

- High reticulocyte count - High unconjugated bilirubin - High lactase dehydrogenase - Low haptoglobin – removes free plasma Hb within blood stream

Answer 11

Enhanced recovery after surgery (ERAS) involves the standardised implementation of multidisciplinary evidence-based interventions during the perioperative period. Looks at interventions pre op, intra op and post op that can increase patient recovery to improve outcomes and reduce stays and cost

Answer 12

- Patient selection - Assessing risk and fitness for surgery - Managing and optimising comorbidities e.g. anaemia - Patient education - smoking and alcohol cessation - optimise nutrtion - prehabilitation programme - psychological support - Assess co-morbidities and further optimisation and planning e.g. diabetics first on list - Carbohydrate loaded drink – minimises metabolic consequences of fasting , optimises hydration and improved outcomes

Answer 13

- Target fluid therapy o Avoid over hydration – pulmonary/cardiac dysfunction, bowel oedema and poor wound/anastomoses healing. o Avoid under hydration – poor organ perfusion - Minimise PONV – TIVA, antiemetics, avoid N20 - Multi-model analgesia – regional techniques? - blood conservation strategies - TXA - normothermia

Answer 14

- Early mobilisation reducing VTE risk and pneumonias - Better patient experience - Reduced hospital stays - Reduced cost to health service - Reduction in surgical site infection - Maximises case numbers / minimises cancellations

Answer 15

The process of enhancing an individuals functional capacity to enable them to withstand the stress of surgery. Major surgery is associated with a significant decline in functional capacity Multimodal approach: - medical optimisation - preoperative exercise programmes - nutritional support - Stress/ anxiety reduction - Life style changes – smoking and alcohol

Answer 16

smoking alcohol weight optimisation anaemia blood glucose measurement pharmacology of chronic disease optimisation

Answer 17

- Reduces insulin resistance - Promotes anabolism - Reduces muscle catabolism - Reduces the stress response to starvation - Maintains glycogen stores during starvation

Answer 18

- Pulmonary fibrosis – restrictive defect / reduced compliance - Effusions – reduces compliance / FRC - Costochondral disease – reduced chest wall compliance

Answer 19

- Inflammatory pericarditis + effusions – restrictive pericarditis affecting filling, rarely tamponade - Accelerated atherosclerosis and CAD due to chronic inflammation - Rheumatoid nodules – damage valves or cause conduction defects

Answer 20

o Autonomic dysfunction o Peripheral neuropathy o Carpel tunnel - Compression of nerve roots e.g. in C spine

Answer 21

- Cricoarytenoids – stridor, obstruction at the cords, difficult airway - - TMJ involvement – poor mouth opening , may need fibreoptic nasal intubation - - Atlanto-axial instability – risk of subluxation and spinal cord compression on airway manipulation. May need awake firbeoptic - - Cervical ankylosis – limits neck extension – difficult airway - - Cortovertebral / costotransverse joint ankylosis – restrictive lung defects - - Interphalangeal joints/ metacarpophalangeal joints – limits ability to use PCA

Answer 22

lateral C spine Xray distance between the atlas and the odontoid peg exceeds 4 mm in patients older than 44 yr and 3 mm in younger patients

Answer 23

anterior - most common posterior verticle lateral

Answer 24

- This is a disorder where there is excessive movement between C1 and C2 as a result of either bone (odontoid peg erosion) or ligament (transverse ligament weakening/stretching) - This can result in movement and cord compression during neck movement - Subluxation can occur resulting in compression of the spinal cord and quadriparesis

Answer 25

identify cricothyroid membrane - particularly useful in those predicted to have difficult airway or obesity prepare for tracheostomy - identifies level, blood vessels , distance of trachea from skin tracheal size guide - can measure the diameter of trachea to pick correct tube size - good for paediatrics and tracheal stenosis can confirm tracheal intubation - good if capno is unreliable (severe bronchospasm, low cardiac output), and quicker than capno. (capno still gold standard) prediction of difficult airway

Answer 26

urology - prostate pelvic cardiothoracic general

Answer 27

less blood loss better post op pain increased sterility and hence less wound infections faster recovery and reduced hospital stay better image / depth than laparoscopic better control and dexterity than laparoscopic

Answer 28

limited acess to patient from surgeon - hard in emergency steep trendelenberg and pneumoperitoenum alter physiology patient movement can have potentially disatrous consequences - need deep NMBA long proceedure high cost

Answer 29

effect from intra abdominal pressure * compression of vena cava - reduced CO * compression of aorta - high SVR * venous pooling - DVT risk * risk of ischaemia to bowels/ kidneys effect from steep trendelenberg * low FRC, atlectasis, V:Q * low compliance and high pressures * cerebral / orbital / facial oedema * risk of reflux effect from CO2 * respiratory alkalosis

Answer 30

restriction of fluids regularly inspect face leak test for airway oedema avoid tube ties

Answer 31

- Patient sliding off o Straps and non slip padding used - Pressure injuries – o Gel and padding - Oedema e.g. cerebral oedema - restrict fluid - - Compartment syndrome – lithotomy/ Trendelenburg o Avoid compression stocking o Period levelling out - Upper limb neuropathy – o Support head an d neck position

Answer 32

SS/ scleroderma is a rare autoimmune multi system inflammatory connective tissue disease characterised by fibrosis and small vessel vasculopathy * More common in women * 30s-50s

Answer 33

* Limited cutaneous - limited to peripheries (distal to elbows/ knees) o Anti centromere * Diffuse cutaneous - extending proximally o Anti Scl70 / topoisomerase

Answer 34

o Calcinosis – calcium deposits under skin - fingers o Raynauds – vasospasm of arteries , distal ischaemia and necrosis o eosphageal dismotiliy – reflux, oesophagitis o syslerodactyl – thick and tight fingers , limited mobility. Early disease puffy hands progressing to sclerodactyly o telangiectasia – spider veins , around nose and hands

Answer 35

o Respiratory  Lung fibrosis  pulmonary artery HTN – cor pulmonale o cardiac involvement  cardiac fibrosis and confuction defects  coronary artery disease o scleroderma renal crisis o Haematological  Microangiopathic haemolytic anaemia – RBC damaged by small vessels  Anaemia of chronic disease  Associated with antiphospholipid syndrome – risk of arterial and venous thrombus.

Answer 36

- Immune modulation – steroids, rituximab - Vasodilators – CaCB, prostacyclin analogues - Cardiac management – ACEi, diuretics, anti HTNs - GI – antacids/ PPI

Answer 37

- Involve rheumatology for assessment of severity and extent of disease , medication optimisations and to help with post op complications - Detecting and optimising subclinical severe cardiac and respiratory comorbidity - Review of medications - Degree of dysphagia and reflux – aspiration risk – may need RSI - Joint contractures – affecting intubation / positioning - Renal involvement - Problems with monitoring from raynauds/ sclerodactyly - Any associated auto immune conditions e.g. antiphospholipid syndrome

Answer 38

o Limited neck movement o Aspiration risk - RSI o Microstomia from fibrosis – avoid nasal intubation – risk of bleeding from small nasal passage can have pre op mouth physiotherapy to increase size of mouth opening

Answer 39

risk of fibrosis / pulmonary artery HTN avoid intubation and ventilation if possible fibrosis - lung protective volume 6ml/kg, avoid PEEP PAH - avoid hypoxia, acidosis, hypercarbia, hypothermia

Answer 40

Blood pressure - thick skin and flexion contractures may make non invasive monitoring difficult / inaccurate - may need arterial line however not in radial as this has risk of vasospasm and distal ischaemia pulse ox - poor trace in raynauds/ thick skin, may be limited where probe can be placed. ear probe may be used.

Answer 41

* scleroderma renal crisis * catastropic antiphospholipid syndrome * MIs * acute PAH crisis

Answer 42

Hereditary: Pre junctional: * Peripheral neuropathies – Friedrich ataxia and charcot marie tooth Post junctional * Dystrophies – Becks and Duchennes * Myotonias – myotonic dystrophy * Metabolic/ mitochondrial disorders Acquired Pre junctional * MND * MS * Guillian barre * Peripheral neuropathies e.g. diabetes Junctional * Myasthenia gravis * Eaton lambert syndrome Post junctional * Inflammatory myopathy * Critical illness polyneuropathy

Answer 43

duchenees X link recessive dystrophin gene

Answer 44

- Autoimmune disease - IgG to nicotinic Ach receptors leading to receptor destruction at NMJ - Fatiguable muscle weakness - Predominantly small muscles e.g. facial - Affects ocular, bulbar and respiratory muscles – diplopia , ptosis , dysarthria

Answer 45

- Symptomatic treatment with medium acting anticholinesterase inhibitors – pyridostigmine - Thymomectomy - Immunosuppression – steroids / azathioprine - IVIg / plasma exchange - for acute deterioration / respiratory involvement

Answer 46

non depolarising - more sensitiive, use 10% of dose depolarising - less sensitive - use more. however hard to predict, can lead to phase 2 blcok some anaesthetists may avoid NMBA - e.g. remifentanil or deep anaesthetic use ToF to quanitfy

Answer 47

atropine glycopyrolate

Answer 48

- Infection - Surgery / stress - Pain - Residual NMBA after anaesthetic - Hypo/ hyperthermia - Drugs – aminoglycosides, Beta blockers, steroids , macrolides, magnesium, CaCB, phenytoin

Answer 49

- Thymoma - Autoimmune thyroid disease - Autoimmune diabetes - SLE - RA - Addisons - Cardiac abnormalities – conduction defects, myocarditis

Answer 50

o Pre op  Detailed assessment of respiratory and bulbar function  Exclude other autoimmune diseases  Optimise treatment  Airway assessment although thymomas rarely cause tracheal compression  Plan post op bed – ventilation o Peri-op  Avoid premed sedatives due to resp weakness  Periop steroid cover if on regular steroids  Resistant to depolarising NMBA e.g. sux – need larger dose  Sensitive to non depolarising – 10% of normal dose  Neuromuscular monitoring throughout the case  Anti-cholinesterases – avoid these as may already be on them and then can result in cholinergic crisis. Continue usual anticholinesterase  Drugs interfering with NMJ should be avoided e.g. gentamicin o Post op ventilation may be necessary , nurse in HDU

Answer 51

- Immune related disease often associated with malignancy e.g. small cell carcinoma - Ab against VG Ca channels – pre synaptic - Prevent acetylcholine release - Weakness that improves with more movement – more commonly proximal muscles - most patients also have autonomic invovlement

Answer 52

eaton lambert - sensitivity to both non and depolairisng NMBA (MG resistance to depolarising) eaton lambert - autonomic involvment presentation - eaton lambert proximal larger muscles and improves with activity

Answer 53

Rare multi-system autosomal dominant neuromuscular disorder affecting skeletal, cardiac and respiratory muscles. This is a trinucleotide repeat disorder on chromosome 19 resulting in abnormal sodium and chloride channels displays anticipation - worse with succesive generations

Answer 54

o Myotonia e.g. hyperexcitable muscle and difficulty releasing grip o Distal muscle weakness – reduced dexterity of hands and foot drop o Muscle wasting - good positioning / padding o Avoid sux – masseter spasm, laryngospasm, hyperkalaemia. Non depolarising NMBA are safe o Avoid neostigmine and neuromuscular monitoring – can induce myotonias avoid triggers

Answer 55

**conduction defects and cardiomyopathy )** * o regular ECG and ECHO checks. * o may have pacemakers / ICDs - ECG monitoring and external pacing available * o LV failure - may need central line and ionotropes * o May also have pulmonary hypertension due to chronic hypoxia * o Risk of embolic strokes from arrhythmias **restrictive lung disease and OSA** * o Respiratory muscle weakness and hence failure may need period of ventilation after op * o Bulbar weakness – weak cough and risk of resp infections peri operatively * o Bulbar weakness – risk of OSA – may need NIV * o Restrictive lung defects with progressive spinal deformities

Answer 56

- GI o Bulbar weakness, risk of aspiration o Delayed gastric emptying and constipation o Increased risk of gallstones – reduced smooth muscle activity RSI may be neccessary - Endocrine o glucose metabolism abnormalities o increased risk of hypothyroidism and hypogonadism monitor glucose

Answer 57

intellectual impairment issues around capacity / consent / behavioural issues at induction

Answer 58

hypothermia, shivering, electrical/mechanical stimulation pain

Answer 59

sux neostigmine

Answer 60

remove triggers Na channel blockers - Local anaesthetic / class I antiarrhythmics e..g lidocaine/ phenytoin

Answer 61

a dynamic, non-invasive assessment of the cardio pulmonary system at rest and during exercise which aims to determine functional capacity

Answer 62

o Anaerobic threshold (AT) o Peak oxygen consumption (VO2 peak) o Ventilatory efficiency for CO2 (VE/VCO2)

Answer 63

The threshold at which the O2 demand exceeds the capacity for cardiopulmonary system to supply O2 and there is a increase in CO2 secondary to anaerobic respiration and lactate production. Measured in mlO2 /kg /min (Lactic acid produced which is buffered by bicarbonate generating further CO2 - So CO2 production suddenly rises and O2 consumption doesn’t).

Answer 64

risk score is a simple tool usually additive variables risk prediction model uses more data and complex algorithms to predict % risk of specific outcome e.g. mortality

Answer 65

- ASA grade = American society of anaesthesiologist o Simple to use and familiar but not very detailed and inter-user variability o ASA 1 = normal healthy person o ASA 2 = mild systemic disease e.g. mild lung disease o ASA 3 = severe systemic disease o ASA 4 = severe systemic disease constant threat to life o ASA 5 = moribund patient not expected to survive without operation o ASA 6 = patient for organ donation with brainstem death

Answer 66

ASA Lees revised cardiac risk index goldmans cardiac risk index

Answer 67

P POSSUM NELA - national emergency laparotomy audit SORT = surgical outcome risk tool

Answer 68

Portsmouth physiological and operative severity score for the enumeration of mortality and morbidity o Applicable to emergency and elective patients major general/urology and vascular patients o Physiological variables and operative variables o Estimates 30 day M&M

Answer 69

- 6 min walk test - how far can they walk, should be >500m - Incremental shuttle walk test - cones progressively placed further apart. same time to get to each - CPET

Answer 70

o Acute MI (3-5days) o Unstable angina o Uncontrolled arrhythmias o Syncope o Endocarditis o Acute PE o Pulmonary oedema o Uncontrolled asthma

Answer 71

- Electromagnetically braked cycle ergometer - Rapid gas analyser – uses pressure differential pneumotachograph - Non invasive BP, ECG, O2 sats

Answer 72

- Chest pain - ECG changes – ST depression / elevation - Drop in blood pressure / hypotension - Claudication - Musculoskeletal pain - Dyspnoea / significant O2 desaturation - Severe HTN - Confusion / reduced consciousness

Answer 73

Pannel 5: change in gradient of VCO2 production - V slope method the VCO2 is plotted against VO2 and the gradient of graph changes when AT is met because more CO2 is made in comparison to O2 being used at this point. The inflection point = AT Pannel 6: the nadir of the VE/VO2 curve - increase in VT/O2 and normal or drop in VT/CO2 – i.e. hyperventilation occurs but O2 cant increase and hence VT/O2 increases

Answer 74

- VO2 peak - Peak work rate - Anaerobic threshold

Answer 75

- Exercise limiting PVD - Lower limb amputation - Severe arthritis - Learning difficulties / dementia – unable to follow instructions - Balance / coordination problems e.g. post stroke

Answer 76

A group of chronic conditions that cause intermittent partial or complete cessation of breathing during sleep. e.g. **Obstructive sleep disordered breathing** * partial airway obstruction - snoring * upper airway resistance sydnrome * OSA * obesity hypoventilation syndrome **Central sleep disordered breathing**

Answer 77

* Simple – enlarged adenoids or tonsils in otherwise healthy children * Complex – associated with craniofacial syndromes, genetic disorders, obesity or neuromuscular disorders * Central sleep disordered breathing is due to brainstem dysfunction or restrictive disease from neuromuscular disorders or thoracic deformities

Answer 78

trisomy 21 Robin Pierre Treacher collins

Answer 79

still get snoring and gasping however also neck extension and less common to have daytime sleepiness instead difficult concentrating / hyperactive nocturnal enuresis also a symptom

Answer 80

Polysomnography (PSG) is gold standard - same in adults other options.. * overnight pulse ox * Cardiorespiratory sleep studies - same as PSG but simplified * ambulatory sleep study - in childs house

Answer 81

gold standard sleep study for diagnosing sleep apnoea it has .. * Respiratory channel = nasal airflow, thoracoabdominal movements, oximetry, end tidal CO2 monitoring * Cardiac channel = ECG and pulse ox * Body position channel * Snore microphone * Video * Neurology channel – EEG to identify sleep stages

Answer 82

labour intensive not in own environment expensive

Answer 83

APNOEA = >90% airflow reduction for >2 breaths or >10seconds HYPOPNEA = >30% airflow reduction for >2 breaths or >10seconds with 3% desaturation or EEG arousal The number of apnoea / hyponoeas are counted per hour and can be categorized * <1 = normal * 1-5 = mild * 5-10 = moderate * >10 = severe

Answer 84

Polysomonography - gold standard o Normal – up to 5 apnoeic / hypopnea episodes per hour o Mild = 5 to 15 per hour o Moderate = 15-30 o Severe >30 / hour

Answer 85

* Severe OSA * Prematurity * Home O2 use * Neuromuscular disease * Elective tracheal intubation * Age <3yrs * Airway anomalies

Answer 86

STBUR questionaire Snore more than half the time? Snore loudly Trouble breathing Breathing stops during the night Unrefreshed when wakening

Answer 87

- Men - Obesity - Adeno-tonsillar hypertrophy - Craniofacial abnormalities - downs / treacher collins - acromegaly - neuromuscular disorders e.g. myotonic dystophy

Answer 88

**Loss of stage 3 and REM sleep** * o Day time sleepiness * o Poor concentration * o Irritability * o Anxiety / depression -** Hypoxia ** - pulmonary vasoconstriction and RHF **- CVS: ** HTN, AF, MI, stroke , CHF - ** - Impaired glucose tolerance - Increased cortisol **

Answer 89

- STOP BANG questionnaire o Snoring o Tireness o Observed apnoeas o Pressure – HTN o BMI >35 o Age >50 o Neck circumference >40cm o Gender = male - Score of 0-2 low risk, 3-4 intermediate risk , >5 high risk

Answer 90

- Lifestyle modification.. o Smoking cessation o Weight loss o Alcohol reduction - Nasal CPAP o Overnight CPAP set at +5 to +20 cmH20 – acts as a pneumatic splint to maintain upper airway patency o Improves symptoms and CVS complications e.g. HTN and AF o Elective surgery should be postponed for 3 months of treatment with CPAP - Mouth devices that promote jaw thrust - Surgical uvulo-palato-pharyngoplasty

Answer 91

- Pre op o Airway assessment + plan difficult airway o Use of CPAP – plan for post op ITU / use of own CPAP o Optimise other comorbidities e.g. HTN, diabetes - Induction o Regional preferred to general if possible o Risk of upper airway obstruction  Good jaw thrust , 2 person technique, guedel  High flow nasal oxygen  Good pre oxygenation  Sitting position / head up – max FRC  Anaesthetic agents reduce respiratory drive and pharyngeal muscle tone. o Avoid I gels – more likely to obstruct / aspirate o Multimodel analgesia – more sensitive to depressant effects of opioids so limit these to avoid prolonged emergence - Emergence o Residual NMBA fully reversed o Maximise position for FRC o CPAP in recovery o May need HDU

Answer 92

polysomnography - gold standard overnight pulse ox - easier , less accurate

Answer 93

- Weight loss - Smoking cessation - Reduction in alcohol

Answer 94

Modern continuous-flow centrifugal pumps which are preload-dependent and afterload-sensitive that provide circulatory support for patients with end stage HF. They can be temporary or long term (durable VADs). They can support LV, RV or both (biventricular devices)

Answer 95

* Inflow cannula into LV – drains blood * Drains blood into a pump (may be located in pericardial space) * An outflow cannula to ascending aorta * Controller and battery are both connected to pump * Touch screen can be connected to controller for viewing settings and altering, plus alarms

Answer 96

* Supporting patients waiting for transplantation e.g class IV HF * Long-term support for patient’s ineligible for transplantation. e.g class IV HF * Bridge to recovery: Temporary support allowing myocardial recovery e.g post partum cardiomyopathy, MI .

Answer 97

Bleeding, particularly gastrointestinal bleeding. * Continuous flow devices predispose to AV malformations * Patients also on anticoagulation * GI bleeding is common – up to 40% of patients Infections involving the driveline or pump pocket. Stroke. Pump thrombosis. Right ventricular failure. Secondary organ dysfunctions (respiratory, renal, hepatic).

Answer 98

- Target INR 2-3 - Typically warfarin + aspirin (+/- clopidogrel)

Answer 99

MDT approach - cardiologist, anaesthetist, VAD specialist nurse evaluate patient pre op - VAD function, RV function, ECHO, functional status anticoagulation changes - stop warfarin 5 days before, start IV heparin once INR < 2 and start 2-4 hours before surgery. psychological support post op planning

Answer 100

AABGI invasive blood pressure consider tranoesophageal echo for fluid status / cardiac function other to consider CVC BIS - HTN and tachy response may be appropriate to indicate a light anaesthetic.

Answer 101

60 -80 below 60 - poor purfusion above 90 - risk of aortic regurg and pump thrombosis

Answer 102

o Head up position – reduces pre load and hence pump flow o Pneumoperitoneum – reduces preload and afterload VAD are pre load dependant and afterload sensitive. If preload is v. low - risk of suction event – the device will try to pull further blood causing collapse of ventricle and possible blockage of the inflow cannula - CVS collapse, myocardial damage and arrhythmias if afterload is high - flow can also be impaired

Answer 103

- Inadequate pre load - Pump is dependant on preload - Causes LV to collapse and occlude the inflow cannula - Severe hypotension, ventricular arrhythmias, low flow alarm will sound - Caused by hypovolaemia, RV failure, cardiac tamponade , reduced venous return (pneumoperitoneum, trendelenberg) - Management – reduce pump speed, IV fluid bolus, address cause, use echo to guide treatment

Answer 104

suction event pump thrombosis RV dysfunction cardiac arrest

Answer 105

- Defib and cardioversion are safe - Chest compressions are relatively contraindicated because of damaging the device however may be necessary if MAP < 50mmHg or EtCO2 < 20mmHg

Answer 106

permanent pacemaker cardiac resynchronisation therapy device Implantable cardiac defibrilator loop recorder

Answer 107

ventricular assist devices are not considered as CIED, these are mechanical pumps for HF and CIEDs are supporting electrical function

Answer 108

* symptomatic bradycardia from sinus disease i.e. sinus brady * sick sinus syndrome * 3rd degree heart block * 2nd degree HB type 2 * Unexplained syncope and bifascicular block *

Answer 109

Combination of pacemaker and defibrillator activity – help coordinate contractions of heart chambers, especially for HF paitents

Answer 110

Symptomatic HF with LVEF < 35% despite optimal medical therapy where there is LBBB and QRS >130ms and patients otherwise in sinus rhythm Same as above but QRS > 150ms without LBBB Same as above (symptomatic, EF<35%, QRS> 130, ideally >150) with AF Strongest evidence if LBBB and QRS >150

Answer 111

o Primary prevention of life threatening arrhythmia – e.g. familial condition – long QT, Brugada o Secondary prevention - previous life threatening arrhythmia leading to cardiac arrest, previous sustained symptomatic VT, asymptomatic VT associated with HF (LV < 35%, NYHA < 3)

Answer 112

For investigation of cardiac arrhythmias that are not detected by ECG, 24 or 72 hour halter monitors.

Answer 113

- **Change response mode to asynchronous mode** = this is if there is significant pacemaker dependency e.g. pacing spikes before most complexes. This is because the pacemaker may misinterpret the diathermy as activity and stop pacing. In these cases default pacing rate is chosen. - **Advanced CIED functions may cause unhelpful rate changes periop** e.g. sometimes rate response uses minute ventilation to regulate pacing when sleeping / resting - **Defibrillator function** – switched off to eliminate risk of firing in response to electromagnetic interference if diathermy is used.

Answer 114

- Asynchronous mode if very reliant on pacing if surgery above umbilicus - Bipolar diathermy - If monopolar needed, place the diathermy plate distant from pacemaker - Short rather than long bursts of diathermy

Answer 115

- Transcutaneous pacing - Correcting cause e.g. electrolyte abnormalities, hypoxia, CO2, releasing surgical stimulus

Answer 116

- Atropine 500mcg - Glycopyrrolate 200mcg - Isoprenaline 5mcg/min - Adrenaline 2-10mcg/min

Answer 117

- Atelectasis - hypoxaemia - Pneumonia - Pneumothorax - Bronchospasm - Aspiration pneumonitis - Pleural effusion

Answer 118

o Obesity BMI >40 o Age >60 o ASA >/= 2 o Frailty o Lung disease e.g. COPD o Congestive cardiac failure o Long term steroid use / immune deficiency o Smoking o Recent upper respiratory infection

Answer 119

o Long surgical time >3 hours o Abdominal surgery, head and neck, major vascular and neurosurgery o Emergency surgery

Answer 120

- Anaesthetic gases impair hypoxic vasoconstriction – worsen V:Q - Opioids reduce cough response and mucociliary function – increase infection risk - Dry gas’s = mucus production and plugging - Residual NMBA – impair cough / worsen ventilation – aspiration, atelectasis - Absorption atelectasis with 100% O2 - Supine surgery – closing capacity > FRC , atelectasis and V:Q mismatch - Biting on tube at the end – negative pressure pulmonary oedema - Poor pain management post op – reduces cough / mobilisation – pneumonias

Answer 121

- Stop smoking - Optimise cardio respiratory disease - Prehabilitation exercise programme

Answer 122

- Lung protective ventilation + PEEP to splint open airways - Full reversal of NMBA with neuromuscular monitoring - Avoid 100% O2 - Goal directed fluid therapy - If possible – slight head up / peep to avoid closing capacity > FRC - Good suction before removing tube – preventing secretions being aspirated

Answer 123

- Adequate analgesia - Early mobilisation - Lung expansion / respiratory physiotherapy

Answer 124

Atelectasis is the collapse of airways / alveoli leading to reduced ventilation, gas exchange and V:Q mismatch - Decrease in FRC , o Abdominal content / diaphragm push up on bases of the lungs to reduce volume of air left in lungs at end of normal exhalation o Worse by trendelburg / pneumoperitoneum o closing capacity is above this and small airways close at the end of normal expiration before alveoli are empty. The gas is absorbed from these alveoli and they eventually collapse - this collapse results in hypoventilation to these areas and shunting – V:Q mismatch – hypoxia - - anaesthetic gases / opioids reduce ventilation – small volumes if spontaneous breathing, further alveolar collapse and lungs aren’t being as expanded with each breath - - absorption atelectasis – oxygen is absorbed into blood and no N2 to splint alveoli open - - mucus plugging may also contribute – behind plug, no air entering so collapse

Answer 125

neurodegenerative disease due to degeneration of dopaminergic neurons in the substantia nigra pars compacta (SNc) leading to dopamine deficiency. It results in classic triad of bradykinesia, rigidity and asymmetrical resting tremor.

Answer 126

- Multisystem disease effecting motor, neuropsychiatric, autonomic NS - Early non-motor symptoms = tired, depression, sleep disturbance - Later motor symptoms = gait change, small hand writing, soft speech, postural instability, dysphagia - Later neuropsychiatric = slowed cognition, dementia - Autonomic = postural hypotension, sexual dysfunction, urinary dysfunction - Classic triad = Bradykinesia , Muscle rigidity and Assemtrical resting tremor

Answer 127

**dopamine receptor agonists that do cross BBB** * Ropinirole , apomorphine , bromocriptine * Used as monotherapy in early PD **dopamine precursor** * Levo dopa – converted to dopamine in CNS by dopa decarboxylase * Also converted in periphery – to prevent peripheral side effect carbidopa combined to block peripheral dopa decarboxylase **inhibit breakdown** * MAO- B inhibitors - selegiline * COMT inhibitors – entacapone * Cholinesterase inhibitors

Answer 128

* Peripheral side effect of dopamine = tachycardia, arrhythmia, nause

Answer 129

o Involve PD specialist nurse o Neurological assessment o Dementia and behavioural issues o airway assessment - osa, reflux , fixed flexions o May need to switch oral meds to transdermal / subcut infusion o Careful with drugs – avoid dopamine antagonists (metoclopramide, droperidol etc) o DBS device – see later o Careful positioning – rigidity o First on list to minimise changes to drug / more predictable timings o post op ventilation / ITU

Answer 130

o Phenothiazine = prochlorperazine o Butyrophenones = droperidol – o Benzamines e.g. metoclopramide

Answer 131

dopamine receptor antagonist but cant cross BBB

Answer 132

a safe and effective treatment for Parkinson’s patients, essential tremor, dystonias and refractory epilepsy. - Modulates neural activity of the cortico-striatal-palliadal-thalmic-cortical circuit

Answer 133

STN (subthalamic nucleus) and Globus pallidus interna are common targets for treating PD symptoms. - Ventral Intermediate Nucleus (VIM) stimulation is effective for essential tremor (ET) in the upper limb. - - GPi stimulation is used for treating dystonia.

Answer 134

**- Patient factors** o Rigidity / tremor – difficulty positioning o Cognitive impairment o Autonomic dysfunction – BP changes o Delayed gastric emptying – aspiration risk o Restrictive lung disease **- Medication factors** o Levo dopa – critical timings required, awareness of parkinsonism crisis o Interactions with anaesthetic agents – avoid metoclopramide, haloperidol. **- Procedure related** o Usually require intra op transfer to CT / MRI o Extended duration of surgery – patient fatigue / irritability o Complications – VAE, seizures, haemorrhage o Rigid head frame limits airway access

Answer 135

 Severe cognitive impairment e.g. dementia or psychosis is a contraindication

Answer 136

local anaesthetic sedation - dexmedatomidine GA

Answer 137

**- Airway:** o More likely with LA / sedation cases o A LMA may be used to stabilise airway without removing headframe **- Breathing** o Higher risk of respiratory complications e.g. aspiration, laryngospasm, pneumonia, sleep apnoea (sedation worsens) **- CVS:** o Vasovagal responses, autonomic dysfunction and arrhythmias o Intra op HTN is a risk of intracranial haemorrhage – close BP management is critical o VAE **- Neuro:** o Intracranial haemorrhage - o Seizures o Parkinson hyperpyrexia syndrome – medication withdrawal / surgical stress – parkinsonism, hyperpyrexia and autonomic dysfunction o Cognitive – confusion , Depression, mania, hallucinations **Technical:** o Hardware problems - Infection , lead migration, device malfunction o Stimulation related problems- Usually reversible but include dyskineasia, worsened balance / gait. Need to adjust parameters

Answer 138

age over 64

Answer 139

Pre op: - Standard pre op assessment - Assess DBS functionality , type and location - Understand the condition requiring DBS and symptoms when switched off.- plan for symptom management when switched off. - Input from specialist nurse is crucial - Device usually turned off at induction and reactivated before emergence Intra op - Avoid using diathermy and monopolar electro surgery in patients with implanted devices. o Risk of heating implant and hence brain tissue o Bipolar preferred , monopolar plate away - Monitoring interference – DBS can disrupt EEG and ECG – deactivating DBS can help Post op - Ensure proper functioning of DBS - Monitor patients’ neurology - Resume parkinsons meds asap Other - MRI – only possible with specific safe devices, may lead to heating, malfunction - consult the manufacturer’s guidelines before - ECT is contraindicated - External defibrillation – can damage DBS device, turn off before cardioversion

Answer 140

- Aspiration due to gastroparesis – pneumonias - OSA – airway obstruction and hypoxia at induction/ emergence - Restrictive lung disease due to rigidity and dyskinesia – poor gas exchange and ventilation periop - Fixed flexion deformity of C spine – difficult intubation - Poor swallow / clearing secretions – post op pneumonias / laryngospasm

Answer 141

- Rotigotine = transdermal patch – MAO-B inhibitor - Apomorphine = Subcut infusion – dopamine receptor agonist

Answer 142

- Off period – increasing rigidity , tremor and bradykinesia - Parkinsonism hyperpyrexia / neuroleptic malignant syndrome – serious effect of withdrawal of levodopa – fever, rigidity, CVS instability, agitiation / delirium - Dopaminergic agonist withdrawal syndrome = anxiety, depression, nausea, sleep disturbance , sweating

Answer 143

Psychiatric eating disorder characterised by a severe restriction of energy intake because of the intense fear of gaining weight. It affects most body systems

Answer 144

* the restricting’ type (weight loss through dieting, with or without excessive exercise) * the ‘binge eating and purging’ type - binge eating in combination with self-induced vomiting /laxatives).

Answer 145

- Poor dentition from vomiting / nutritional deficiency - Risk of aspiration from delayed gastric emptying and repeated vomiting – RSI - May have tracheal stenosis from repeated vomiting / aspirations - if at risk pre op bronchoscopy

Answer 146

- Hypoventilation secondary to metabolic alkalosis secondary to vomiting - Maintain hypoventilation as hyperventilation may precipitate further alkalosis and hypokalaemia - (K exchanged for H). Ideally frequent ABG sampling to optimise ventilator setting.

Answer 147

- Low cardiac output – due to low muscle mass & venous return and activation of parasympathetic NS leading to bradycardia - Cardiac mass often decreased due to catabolism - As a result often hypotensive with high SVR - Risk of cardiomyopathy - Risk of arrhythmias from electrolyte disturbances - Pre op ECHO and ECG - Arterial line is advised – close haemodynamic monitoring and frequent ABGs - Careful fluid balance - likely to be dehydrated but avoid overload

Answer 148

- Risk of refeeding post op - Risk of hypoglycaemia – poor reserves - Oesophagitis from vomiting

Answer 149

- Common to have AKIs / CKD from dehydration - Electrolyte abnormalities

Answer 150

- Vitamin K deficiency – coagulopathy - Bone marrow suppression – infection risk and anaemia

Answer 151

- Muscle wasting - Osteoporosis - Less fat - Risk of pressure ulcers - care with positioning + movement - lots of padding - Temp monitoring is very important as less fat insulation so prone to hypothermia

Answer 152

- Often co-exists with other psych illness - behavioural issues / depression / anxiety - Create calm environment and careful explanations - Manage post op pain and anxiety

Answer 153

- Airway exam – may need bronchoscopy if risk of tracheal stenosis - ECG, ECHO - U&E - TFT – often have low T3 which can worsen CVS response under anaesthesia

Answer 154

- Bradycardia (< 40 bpm) or SBP < 80 mmHg is a contraindication to elective surgery

Answer 155

- Risk of Refeeding syndrome - Electrolyte shifts - Organ failure

Answer 156

* low fat and muscle change the pharmacokinetic * Absorption- unpredictable for IM/ SC * Distribution - lower VD so higher active drug in plasma * Metabolism - reduced liver function * Excretion - reduced kidney function * Dose based on actual body weight * TCI models aren’t valid * Altered distribution of propofol - careful tittering at induction especially with CVS disease * Avoid succinylcholine – risk of hyperkalaemia and arrhythmias

Answer 157

- Vital signs unstable (e.g. HR < 40 bpm, SBP < 80 mmHg) - BMI < 14 kg/m² - Signs of organ failure or refeeding syndrome

Answer 158

A serious and potentially fatal metabolic disturbance resulting in fluid and electrolyte shifts that occurs following reintroduction of nutrition in a catabolic malnourished patient Defined by a 10–30%+ drop in phosphate, potassium, or magnesium, or organ dysfunction within 5 days of refeeding.

Answer 159

- Low BMI - Unintentional weight loss >10-15% in last 3 -6 months - Poor / absent nutrition in last 5 to 10 days e.g. post op / ITU / malabsorption - Alcohol use - Low albumin/electrolytes. - Administration of drugs e.g. chemotherapy

Answer 160

- Chronic malnutrition depletes electrolyte stores through reduced intake, cellular stores are used to maintain serum levels of electrolytes. Thus cellular stores become deplete. - Reintroduction of glucose / calories triggers insulin production - Insulin triggers a surge in glycolysis and promotes cellular uptake of glucose, phosphate, potassium and magnesium - This drops serum levels of K, Mg, PO4 - There is also sodium retention and risk of fluid overload and cardiac failure. - There is also a change in the respiratory quotient now carbohydrates are being metabolised, risk of respiratory failure as respiratory muscle are weak and cannot cope with increased CO2 load. - Electrolyte disturbances can result in muscle weakness, seizures, arrhythmias & cardiac failure

Answer 161

hypokalaemia hypophosphataemia hypomagnesemia

Answer 162

low thiamine (B1) this is a cofactor for glycolysis. upon refeeding, it may be inadequate for glycolysis the carb load results in lactic acidosis and ROS causes neuronal death leading to wernickes encephalopathy which can progress to irreversible korsakoff

Answer 163

25-30 kcals / kg / day 50% carbs, 25% fats, 25% protein

Answer 164

- Improved wound healing - Reduces infection risk / improves immune function - Maintains respiratory muscle strength and thus improves ventilator wean and reduces risk of pneumonias - Improved rehabilitation due to skeletal muscle strength - Reduces hospital / ITU stays

Answer 165

water - 25-30ml/kg/day calories - 25-30kcal/kg/day C:P:F = 50:25:25 sodium 1-2mM / kg/ day potassium 0.8-1.2mM/kg/day calcium 0.1mM/kg/day Mg 0.1mM/kg/day phosphate 0.2mM/kg/day vitamins and trace elements e.g. ADEKC, zinc, copper, selinium

Answer 166

specialist dietician

Answer 167

- Increased water due to insensible losses perioperatively and third space losses secondary to stress response - Slow reintroduction of calories – initially 1/3 normal amount – risk of refeeding - Additional replacement of electrolytes guided by blood tests – refeeding risk - IV thiamine and other B vitamins e.g. pabrinex before and during restarting feeds.

Answer 168

* body mass index. Measured by Kg / m2 o Under 16 - severely underweight o 16.5 to 18 - underweight o 18.5-25 - normal o 25- 30 - overweight o Obese class 1,2,3

Answer 169

- MUST score – validated assessment tool – includes BMI, recent weight loss, acute illness - Tricep skin fold thickness - Hand grip strength - Other – albumin

Answer 170

- Stress response to surgery results in catabolism, if stores are inadequate this results in catabolism of skeletal muscle including respiratory muscles - - Risk of o Hypothermia – lack of fat and shivering o Wound infections = poor immunity o Impaired wound healing o Pneumonia o Increased M&M o Increased hospital stay

Answer 171

- 25-30ml/kg/day - 1mmol Na /kg - 1mmol K/kg /day - 1 mmol Cl / kg/day - 50-100g glucose

Answer 172

- History – amount of fluid in last 48hours and activity level, fever, thirst - Examination - Mucus membranes , Skin turgor , cap refil , pulse volume , urine output - Observations – HR and BP - Bloods – haematocrit , hypernatraemia - Invasive – stroke volume variability index , CVP

Answer 173

- Pre op : Dehydration from fasting, bowel preps , acute illness e.g. vomiting /fever - Intra op - 3rd space losses, Blood loss , evaporation from body cavities - Post op – delayed drinking due to PONV, PONV

Answer 174

- Hyperchloremic metabolic acidosis

Answer 175

- Transgender or gender diverse individual is a term that refers to people who identify with a gender which is different to that of their sex assigned at birth - This could be the opposite gender or it could be a non-binary gender (not female or male) - They may or may not have transitioned

Answer 176

- A.k.a gender affirmation - Physical measures – chest binders - Hormonal therapy - Surgery

Answer 177

o Oestrogen and anti androgen o Oestrogen  may be oral or transdermal  VTE risk  Location of patch should be noted as warming devices can increase absorption  May be implications of suggamadex o Anti -androgen  Cyproterone – synthetic progesterone. Risk of liver failure, adrenocortical suppression and anaemia  Spironolactone - risk of hyperkalaemia and volume depletion / AKI. Withhold perioperatively  Bicalutamide – CYP450 inhibitor which increases midazolam conc, increases anticoag effect of warfarin

Answer 178

o Testosterone OSA, hypertension, weight gain

Answer 179

- Breast surgery – augmentation - Genital surgery – penectomy, orchidectomy , vaginoplasty - Head and neck surgery o Mandible angle reduction – may result in oropharynx crowding and airway difficulty o Chin reduction – airway difficulty o Voice surgery  cricothyroid approximation – tenses cricothyroid membrane  Feminisation laryngoplasty – reduces diameter of larynx to raise pitch of voice  Vocal cord shortening and retrodisplacement of anterior commissure (VCSRAC) – endoscopically makes cords thinner, shorter and tighter o Thyroid reduction surgery – scar tissue may distort anatomy for front of neck

Answer 180

- Breast surgery – massectomy - Hysterectomy + oophorectomy - Vaginectomy - Implantation of erection prosthesis - Head and neck o Voice surgery – injection laryngoplasty o Mandible implants – may result in distorted anatomy o Thyroid augmentation – rib grafted to thyroid – risk of recurrent laryngeal damage

Answer 181

- Transgender individuals who are assigned female sex at birth may be pregnant - They may find vaginal examination frustrating - They may be frustrated at the heteronormative set up of obstetric services - Gender neutral language – chest feeding, front hole, birthing person

Answer 182

O:G = 80 B:G = 0.7 boiling P = 58 MAC = 2 SVP = 22.7

Answer 183

O:G = 1.4 B:G = 0.47 SVP = 5200 BP = -88 MAC = 105

Answer 184

physiochemical: * stable and non flammable at room temp Pharmacodynamics: * High oil gas - potent * Low blood gas - rapid * Non toxic metabolites / harmful effects * Non irritant to airway * Ideally sweet odour

Answer 185

sevoflurane - non irritant, sweet smelling. relatively low blood gas and therefore fast Few toxic metabolites (it is metabolised 3-5% releasing fluride ions that can be renal toxic but in this dose are not.)

Answer 186

speeds onset - second gas and conc effect however - adverse effects - PONV, expands air filled spaces, increases cerebral flow and pressure, inhibits vit B12 in long term, bad for environment

Answer 187

MV - resp rate (TV is fixed) CO - HR (SV fixed)

Answer 188

- Pulmonary phase o Influenced by MV, v:q mismatch and alveolar-capillary diffusion o small FRC - quicker onset of inhalation anaesthetic. o Crying increases MV and hence speed of onset - Circulatory phase - delivery of agent to effect site o influenced by cardiac output, cerebral perfusion, delivery to other tissues. o Higher cardiac output slows induction. o Gas induction in low cardiac output states warrant greater precaution

Answer 189

- Difficult IV access - uncooperative child - potential difficult airway - needle phobia

Answer 190

- Absolute contraindication - MH, refusal in child with capacity - Relative contraindication - inadequate fasting, low cardiac output states (valvular obstruction, cardiomyopathy), severe restrictive / obstructive disease where inhalation may be inadequate

Answer 191

Pre op * build rapport * look for Indicators of need for inhalation e.g behaviour * Explain to parent the options and risks - IV vs inhalation * Explain excitatory phase to reassure normal and not pain * oral midazolam * Sip to send – minimise fasting Preparation * AABGI - apply pulse ox while awake but other monitors can be placed when asleep to avoid anxiety * Trained assistant experience in paeds * Emergency drugs - dosed for child’s weight including suxamethonium IM (4mg/kg) incase of laryngospasm * Mapleson F (T piece) - * Play therapist / IPAD / game * Paediatric theatre - children’s wall paper , reduces anxiety Induction * One parent * Age appropriate language - blowing up balloon analogy * High conc of sevo + N20 at the beginning to speed onset * As soon as asleep someone maintaining airway and someone to cannulate

Answer 192

uncoorperative child laryngospasm loss of airway

Answer 193

asthma , URTI , passive smoking , prematurity

Answer 194

- non pharm - play specialist, blow up balloon, calm friendly environment , paeds theatre wallpaper - Pharm - anxiolysis / midazolam

Answer 195

* Restraint: direct force to restrict movement to prevent harm usually without consent * Clinical holding: limited force with the consent to carry out a proceedure

Answer 196

- Increases usage of sevoflurane – high flows, open circuit so not reused ( mapelson F) - Esp with nitrous as this has a GP100 of 300 and depletes ozone - Theatre pollution to staff

Answer 197

o timings, agent ingested o symptoms since  oesophageal obstruction = drooling, odynophagia, chest pain , dysphagia , retching , hiccups  tracheal compression = DiB, cough, wheeze  other – vomiting o PMH, allergies, development o Fasting status o Intention – self harm, accidental o any red flags for safeguarding concerns

Answer 198

o Airway – choking, stridor , exam oral mucosa for ulcerations, bleeding, feel for neck tenderness o Respiratory – coughing, wheeze, signs of respiratory distress o CVS – haemodynamic stability o GI – abdominal tenderness, guarding, rigidity, drooling

Answer 199

o A to E and resuscitation o Bloods o X ray  Of neck in PA and lateral , chest, and abdomen  Reveals radioopaque objects but also pneumoperitoneum, surgical emphysema or pneumomediastinum  oesophageal coins appear round on PA view whereas trachea coins appear round on lateral view  Radiographic diagnosis of magnet ingestion requires two view

Answer 200

- type of ingestion, where ingested, symptoms , comorbidities - - Emergency – within 2 hours o Airway compromise o Complete oesophageal obstruction and unable to manage secretions, o Batteries in oesophagus o Battery in stomach + symptoms o sharp objects in oesophagus o GI malformations o Multiple magnets even if asymptomatic - Urgent – 24 houts o Oesophageal coin, o Sharp in stomach o Magnets o battery in stomach asymptomatic o cylindrical battery in oesophagus

Answer 201

* causative substance - battery or sharp * Large objects > 6cm long * Lead containing substances * Medications or illicit substances * Complex GI malformation – may suffer more from low risk objects than other children

Answer 202

halo sign otherwise likely to be a coin

Answer 203

- Oesophageal perforation - Trachea-oesophageal fistula - Aorto-oesophageal fistula +/- haemorrhage - Mediastinitis - Tracheal stenosis - Stricture formation

Answer 204

- Single magnets typically pass without issue if not too large. - - Multiple magnets, or a magnet plus a metallic object, can be dangerous due to the risk of: o bowel entrapment leading too… o Ischaemia & pressure necrosis o Perforation & sepsis o obstruction - Neodymium magnets are especially hazardous due to their strong magnetic

Answer 205

acids alkalis

Answer 206

* A to E o Tracheal intubation:  as risk of worsening oedema.  ENT surgoen present ready for surgical tracheostomy in severe cases  In less severe cases can observe and keep NBM * IV dexamethasone * Endoscopy within 24hr in symptomatic patients to assess damage * Erect CXR - perforation * Strictures - require dilation * Child protection / safeguarding/ psych * Avoid activated charcoal - ineffective and obscures mucosal injury

Answer 207

pharmacological non-pharmacological

Answer 208

Pharmacological: * residual anaesthetic agent - clearance depends on length of anaesthetic, agent used, individuals body weight / age etc * Opioids * Benzos * Inadequate muscle relaxant reversal * central anticholinergic syndrome * serotonin syndrome Non pharmacological causes * Metabolic disturbances - hypoglycaemia, hyperglycaemia , hyponatraemia, hypothermia , CO2 narcosis * Neurological disturbances - intracranial haemorrhage, ischaemic stroke , seizures + post ictal state * Other - severe hypothyroidism, functional coma / seizures (psychological)

Answer 209

* they reduce the respiratory centres sensitivity to CO2 - Resp depression - can also reduce clearance of inhalation agents * Direct sedation via opioid receptor * Morphine has active metabolites prolonging its effects especially in renal failure

Answer 210

* lithium * Magnesium * Gentamicin * Hypothermia - reduces breakdown * Genetic factors - sux apnoea * Acquired causes of cholinesterase deficiency e.g liver failure , pregnancy * Myasthenia gravis / Eaton lambert

Answer 211

o Suxamethonium apnoea **neuro** o Epilepsy o Neuromuscular disorders – myasthenia, lambert eaton , guillian barre o Pre-existing neurocognitive decline – more sensitive to sedative drugs, risk of central cholinergic crisis **Clearance** o Liver disease – linked to reduced metabolism, hypoglycaemia, acquired plasma cholinesterase deficiency o Renal failure – reduced clearance of drugs , metabolic disturbances **high CO2** o OSA or obesity hypoventilation – causes central respiratory depression o COPD – chronic CO2 retention results in central respiratory depression Endocrine disease – hypothyroid

Answer 212

- Decline in CNS function increases sensitivity to anaesthetic and sedative drugs - Increased fat proportion compared to muscle and other tissue and this acts as a sink for anaesthetic agents - Impaired kidney / liver function with age - Reduced water content / plasma volume – increases conc of water soluble drugs e.g. NMBA

Answer 213

- Hypothermia and rapid rewarming - Haemorrhagic stroke associated with anticoag - Embolic stroke – thrombi from vessel manipulation, air from bypass circuit - Ischaemic stroke due to inadequate MAP to maintain CPP - Electrolyte and acid base disturbance

Answer 214

- Ensure full AABGI monitoring and ventilating - Ensure anaesthetic agents are off and fully reversed NMBA o MAC / BIS / TOF - Neurological assessment - GCS , Pupils - Check temp and BMs - Check ABG for acid base, electrolytes, O2 and CO2 - Review anaesthetic chart - Consider naloxone / flumazenil / suggamadex - CT head

Answer 215

haemoglobinopathy screening using Gel electrophoresis

Answer 216

o Lyses RBC and then checks how well the Hb dissolves in a solvent o HbS is less soluble than normal Hb o However gives false negatives in neonates or if recent transfusion o Wont differentiate between sickle trait or disease

Answer 217

- Autosomal recessive - Chromosome 11 – glutamate to valine on B globin gene – hydrophobic and polymerisation – deforms RBC shape and results in sickling - Most common in west central Africa and central india

Answer 218

- **Small vessel obstruction** due to sickled cells and consequent endothelial inflammation resulting in acute and chronic organ damage and pain – bony crisis, chest crisis. o Also increases blood viscosity , impairs flow - Sheer stress of sickling / unsickling gives RBC shorter life span – **haemolytic anaemia** o Normal RBC life span 120days o Sickle cell – 10-20days

Answer 219

- Acute chest syndrome - Chronic restrictive lung disease - Chronic lung damage and hyposplenism increases risk of pneumonia - OSA from adenotonsillar hypertrophy (this is secondary to chronic anaemia, increased infections and splenic dysfunction)

Answer 220

- Area of lung that is hypoventilating e.g. atelectasis, pneumonia - Low O2 sats in this area – causes sickling of RBC in this are - Occlusion and inflammation of endothelium - Further hypoxia – vicious cycle - Area of lung infarction - Presents as fever, pain, respiratory failure, infiltrates on CXR

Answer 221

- Pulmonary hypertension – due to chronic lung damage from infarction of pulmonary vessels - Ischaemic stroke – vaso-occlusion in cerebral vasculature - Congestive cardiac failure – consequence of pulmonary HTN , direct damage to cardiac blood supply or overload in repeat transfusions.

Answer 222

transcranial doppler to identify the risk transfusion if high risk

Answer 223

- Acute large splenic infarction - Hypersplenism – recurrent vaso-occlusion results in hypersplenism – this can retain and destroy RBC – worsening anaemia - Acute splenic sequestration crisis – rapid enlargement and sequestration – hypovolaemic shock and pancytopenia

Answer 224

increases production of fetal Hb fetal hb doesnt have B globin chains (a2g2)

Answer 225

- Hypoxia - Acidosis - Hypothermia - Dehydration - Infection

Answer 226

- Hypoxia – failure to manage airway or ventilation e.g. positioning of patient can result in atelectasis etc - Infection - Acidosis – pulmonary vasoconstriction and poor gas exchange, hypoxia and sickle. Also promotes sickling itself. - Hypothermia – shivering and blood stasis and vasoconstriction - Dehydration – excessive starvation times, intra op fluid loss, 3rd space losses - Hypercapnia – pulmonary vasoconstriction and consequent poor gas exchange and hypoxia - Hypotension – GA agents or spinal – can result in hypoperfusion and hypoxia and sickling

Answer 227

- O2, analgesia, rehydration – supportive - May require exchange transfusion

Answer 228

o Most commonly caused by calcification with age o rheumatic fever o congenital bicuspid valves Other - radiation induced

Answer 229

* Increasing LV outflow obstruction results in LV hypertrophy * LV hypertrophy leads to Diastolic dysfunction o Impaired LV relaxation and filling hence limited SV and CO. o Higher LV end diastolic pressures – impedes coronary perfusion o Diastolic dysfunction leads to pulmonary congestion and SoB * LV hypertrophy leads to Increased myocardial supply demand mismatch o Increased demand due to larger muscle mass o Decreased supply due to poor perfusion o Coronary perfusion pressure is determined by the difference between Aortic diastolic pressure and LV end diastolic pressure o As blood passes through the narrowed aortic valve, the pressure drops (Bernoulli) and thus reduced perfusion pressure to the coronary arteries. o This alongside the higher LV end diastolic pressures reduces coronary perfusion o Thus puts myocardium at risk of ischaemia * Ejection fraction deteriorates overtime due to o progressive outflow restriction o reduced end diastolic volume o eventually LV dilation o myocardial dysfunction secondary to demand / supply mismatch

Answer 230

* triad o angina like chest pain o syncope o dyspnoea / HF symptoms * Sudden death can occur

Answer 231

o Echocardiography - transoesophageal or transthoracic = Valve area , LV aortic gradient , Peak aortic flow velocity. Also look at other valves and chambers e.g. LV hypertrophy, mitral regurgitation , pulmonary artery pressure. o Left heart catheterisation and invasive haemodynamic measurements o Low dose dobutamine stress test – in conjunction with ECHO or left heart catheterisation o Cardiac CT to measure aortic valve calcium score o Cardiac MRI o Exercise testing – to confirm presence / absence of symptoms

Answer 232

(make sure you know the severe category)

Answer 233

surgical valve replacement Transcatheter aortic valve implantation (TAVI) balloon valvuloplasty

Answer 234

- Usually percutaneous transfemoral approach - catheter inserted retrograde via femoral artery - Others - subclavian , transcarotid - Transaortic – mini sternotomy or thoracotomy to ascending aorta - transapical (via thoracotomy) into LV apex

Answer 235

 Maintaining sinus rhythm – atrial contraction contributes up to 40% of CO – maintain electrolyte levels, acid base, avoid hypoxia/ hypercapnoea, ensure continuation of anti-arrhythmics  Avoid tachycardia – increased demand and less time in diastole to perfuse myocardium – good analgesia / opioids on laryngoscopy  Also avoid bradycardia as this gives low CO and cant compensate by increasing SV - so HR in tight range  Maintain SVR/ MAP – maintains perfusion during diastole. May need vasopressors, reduce anaesthetic agent where possible. Spinal may be contraindicated  Ensure good intravascular volume – maintain preload – already compromised by diastolic dysfunction so want to optimise preload to maximise CO  Maintain good cardiac contractility – avoid excessive anaesthetic agents, may need inotropes and invasive monitoring

Answer 236

- Pain /anxiety– HTN , tachycardia - Dehydration from fasting – inadequate preload - Anaesthetic agents – drop SVR and contractility - Major haemorrhage – iatrogenic injury to aortic root or intrathoracic vessels - Arrhythmia – damage to AVN / bundle of His when inserting valve - Cardiac ischaemia due to occlusion of the coronary ostia (opening) by the implant - Rapid ventricular pacing up to 200bpm during TAVI procedure dramatically reduces cardiac output for up to 10 seconds during valve deployment (positioning) to prevent its migration

Answer 237

* rheumatic heart disease * Endocarditis * congenital - marfans, ehlers danlos, bicuspid valves * degenerative - aortic root dilation with age * connective tissue - RA, SLE * Secondary to aortic dissection * syphilis - rare

Answer 238

- Severe symptomatic AR - Severe asymptomatic with LVEF < 50% - Significant enlargement of ascending aorta

Answer 239

rheumatic fever

Answer 240

Hx - dyspnoea ECHO - mitral valve area, ventricular function and pulmonary artery pressures ECG - often co-exists with AF

Answer 241

- Acute - could be due to papillary muscle rupture with MI - Chronic o Can relate to structural abnormalities of the valve itself (primary) o Or the size and geometry of LV (secondary)

Answer 242

dyspnoea, fatigue , HF

Answer 243

o Regurgitant jet area  Mild < 4cm2  Severe > 8cm2 o Pulmonary artery pressures

Answer 244

conservative / pre op optimisation = diuretics, ACEi post MI etc open surgical repair transcatheter valve repair

Answer 245

- Suitable valve anatomy - too frail for open - chest wall deformity/ previous sternotomy

Answer 246

- When transcatheter repair is contraindicated - Severe primary MR - Suitable for younger lower risk patients - When simultaneous CABG

Answer 247

Active infective endocarditis - - Valve features o Valve area < 3cm o Leaflet length < 6mm o Mean pressure gradient >5mmHg o Calcification at grasping area o Thrombus / mass on valve - risk of embolisation o Valve perforation - Atrial access o Very small left atrium

Answer 248

- Bleeding – access site, retroperitoneal - Delayed pericardial tamponade - New arrhythmias – AF most common - Hypoxia from pulmonary oedema, ASD shunt reversal, mitral stenosis - TOE related injury – oesophageal / gastric - AKI - Device embolization – uncommon but serious – neurological symptoms

Answer 249

 Reduce afterload – allows forward flow / reduces regurgitant volume  Maintain HR / slight tachy/ avoid brady – minimises the regurgitation time and excessive preload.  Preserve sinus rhythm – atrial contraction helps LV filling – may need amiodarone  Maintain contractility – supports forward flow e.g. may want ionotropes  B agonists preferred over vasopressors – as this supports contractility but avoids high SVR  Avoid fluid overload – worsening MR

Answer 250

CVS - reduce preload / LV size to make mitral leaflets easier to grasp e.g. Furosemide, Ionotropes (dobutamine, milronone) , increase PEEP Ventilation - Low TV 3-6ml/kg – help reduce heart motion to assist leaflet grasp - Avoid ventilatory changes when crossing atrial septum or when placing clipds

Answer 251

250-300s heparin given after venous access obtained

Answer 252

o Chest pain radiating to back, acute, severe, ripping o Aortic diastolic murmur o Hypotension / shock o Systolic BP/ pulse deficit difference in limbs o Focal neuro deficit

Answer 253

IABP is a mechanical device that supports heart when it is not pumping effectively It consists of a balloon catheter inserted into the aorta usually through femoral artery The balloon inflates and deflates in sync with the cardiac cycle (counterpulsation)

Answer 254

Inflates in diastole and deflates just before systole

Answer 255

- Inflation forces blood proximally increasing the perfusion of the coronary arteries and thus O2 delivery to LV (coronary perfusion is difference between aortic diastolic pressure and LV diastolic pressures – hence improving aortic diastolic pressures) - Deflation decreases afterload – reduces myocardial wall stress and O2 demand - Inflation may result in NO release from the endothelium which causes coronary artery dilation and improves blood flow and O2 delivery

Answer 256

- Inflation during diastole helps with forward flow of blood e.g. to cerebral vessels etc therefore augments CO of LV - Deflation before systole reduces afterload and hence improves ejection

Answer 257

- Acute heart failure with hypotension - MI with acute LV failure - MI with acute papillary rupture and mitral regurgitation - Low cardiac output after CABG / failure to separate from cardiopulmonary bypass - Unstable angina – bridge for definitive treatment – as it improves O2 blood supply and reduces LV workload/ O2 demand - Support during high risk percutaneous coronary interventions (PCI)

Answer 258

- Moderate to severe aortic regurgitation – device will promote regurgitation - Aortic dissection/ aneursym – can worsen dissection - Uncontrolled sepsis - Uncontrolled bleeding diathesis - End stage HF where no further treatment options – as this is only a temporary measure - Tachyarrhythmia – at rates the IABP cant synchronise with - Untreated peripheral vascular disease e.g. limb ischaemia – this will reduce perfusion

Answer 259

- In the descending thoracic aorta 2-3cm distal to origin of subclavian artery - The distal end should be above the origin of the renal arteries - Fluoroscopic guidance is used to place IABP and check position with Xray or USS or TOE

Answer 260

- ECG triggered o Balloon inflates with the T wave and deflates with peak of R wave - Arterial pressure waveform triggered o Balloon inflates with the dicrotic notch (closure of aortic valve) and deflates just before upstroke on arterial pressure waveform o Better for cardiac arrests as the ECG will no longer be reliable e.g. PEA it will give false impression of cardiac output and may trigger at the wrong time so better to contract with pressure to support heart.

Answer 261

- Any mistiming can lead to haemodynamic instability - Early inflation before aortic valve closes – increases after load and reduces CO , increases O2 demand of LV and can result in aortic regurgitation - Late inflation – causes suboptimal coronary artery perfusion due to inadequate counterpulsation - Early deflation – before onset of systole – suboptimal reduction in afterload , failing to improve myocardial O2 demand - Late deflation – after onset of systole – increased afterload – reduced CO and increased myocardial O2 demand

Answer 262

**Related to vascular access** o Vascular injury – bleeding , haematoma , false aneurysm o Infection o Poor perfusion to limbs distally – worsening PVD or compartment syndrome **Related to device** o Aortic dissection o Cardiac tamponade o Ischaemia due to incorrect placement and blockage of arteries e..g spinal cord, limb, renal, cerebral o Thromboembolism – foreign body promotes thrombosis around catheter (hence anticoagulated), pump will promote embolization o Thrombocytopenia and haemolysis o Ballon rupture and gas embolus – helium used means its rapidly absorbed into blood during this event to minimise this o Dys-synchrony of device **Related to anticoag** o Bleeding

Answer 263

- Helium - Low density means that flow will be laminar to allow for rapid transfer from machine to balloon tip - Rapidly absorbed into blood in event of balloon rupture

Answer 264

This refers to coronary artery bypass grafting on a beating heart without the use of cardiopulmonary bypass An immobilisation device (octapus stabilisation) used to reduce movement of an area of myocardium being operated on.

Answer 265

the disadvantages associated with cardiopulmonary bypass * SIRS response * coagulation and bleeding - platelet dysfunction, consumption of clotting factors * renal dysfunction - fluid overload/ depletion/ electrolytes * post op cognitive dysfunction and stroke * direct aortic damage **Early extubation and reduced hospital / ITU stay**

Answer 266

more technically difficult - moving heart heart needs to be lifted out of the pericardium and this can impair LV filling and cause haemodynamic instability

Answer 267

saphenous vein internal mammary artery radial artery

Answer 268

AABGI awake arterial line 12 lead ECG - conventional ECG altered as heart is out the chest so 12 lead is more accurate TOE echo - regional wall motion abnormalities + air around heart

Answer 269

* lifting heart impairs LV filling * valve distortion and regurgitation * handling can cause arrhythmias * impaired filling from immobilisation * bleeding * ischaemia from vessel anastomoses

Answer 270

Duplicated card

Answer 271

Surgical - Minimise surgical manipulation and stop if major instability - Minimise periods of ischaemia by utilisation of shunts Anaesthetic * arrhythmias - Avoid electrolyte disturbances – keep K+ over 4.5 and give magnesium routinely. treat arrhythmias. maintain temp - hypothermia can cause arrhythmias - Keep HR low / normal – minimises O2 demand and hence reduces effects of ischaemia. And less movement * good coronary perfusion pressure - MAP 70mmHg using fluids, vasopressors - Ensure patient is adequately filled guided by cardiac output monitoring * good communication with surgeon e.g. TOE finding of air

Answer 272

raise ambient theatre temp warm IV fluids hot air warmers temp measurement foil hat

Answer 273

- An extracorporeal circuit which provides physiological support – gas exchange and pumping of blood - Allows a bloodless still cardiac surgical field

Answer 274

any process whereby blood is circulated outside the body

Answer 275

- Mostly central – involving cardiac vessels - Sometimes peripheral vessels can be used – in minimally invasive cardiac surgery

Answer 276

Venous reservoir o Collects blood from heart o Via cannula into right atrium / vena cava o Blood can also be collected from various surgical salvage devices / suction Pump o An arterial pump then pumps blood from a venous reservoir to a heat exchanger and oxygenator Splitting of blood stream o A fraction of the blood is combined with cardioplegia solution and then reintroduced into the coronary circulation proximal to the aortic cross clamp o The remainder passes through an arterial filter and is returned to the systemic circulation – non pulsatile

Answer 277

can alter gas exchange - increase FiO2 or increase flows to remove more CO2 Cardiac output - altering the bypass flow rate. SVR can be altered via patients physiology temperature - heat exchanger haematocrit - add volume to the venous reservoir or remove by ultrafiltration acid base management

Answer 278

pH stat = maintains constant pH regardless of temp - adds CO2 to maintain target pH despite changes in temp alpha stat - allows pH to change with temp. better for long term physiology and protein ionisation

Answer 279

Intraoperative o Clotting of blood in bypass circuit if not anticoagulated / bleeding if anticoagulated o Circuit induces haemolysis and platelet dysfunction , consumptive coagulopathy o Risk of aortic dissection o Risk of gas embolization Post op o Neurological deficit- ischaemic, haemorrhagic or Embolic – e.g. aortic atheroma o SIRS response o Renal dysfunction - Fluid overload / depletion , Electrolyte disturbance

Answer 280

- Adequate perfusion pressures - Normoglycaemia - Temp control - Confirmation of de-airing the heart by surgeon - High risk patients – cerebral oximetry

Answer 281

- Age - Aortic atheroma - Previous stroke - Diabetes - Surgical factor – valve replacements

Answer 282

anticoagulation - giving heparin, measuring ACT , giving protamine / TXA when appropriate temp managment - temp falls in bypass and needs to be normalised before coming off maintain anaesthesia - volatile into CPB circuit or TIVA acid base/ electrolyte corrections before coming off bypass coordinate with team coming off bypass - e.g. expand lungs at correct time, heart progressively filled

Answer 283

- Cardioplegia is the intentional and temporary arrest of the heart during cardiac surgery, achieved by infusing a special cardioplegic solution into the coronary circulation. - This provides a motionless heart for surgery and a degree of myocardial protection

Answer 284

o Cold crystalloid solution o Cold blood o Warm blood - Cold solutions are 4 degrees and protect against ischaemia - Blood solutions have the advantage of increasing O2 delivery and buffering capacity

Answer 285

proximal to aortic clamp - delivered to the heart either by... * anterograde via aortic root / coronary ostium * retrograde via the coronary sinus

Answer 286

- Intermittent aortic cross clamp - Fibrillation techniques o VF is induced to prevent contractions o VF is cardioverted regularly to prevent ischameic damage – should not exceed 10s

Answer 287

- Advantages o Reduction in O2 consumption – reduced risk of ischaemia - Disadvantages o Coagulopathy, impaired membrane function

Answer 288

o Normothermia o Hypothermia – 25-32 degrees = active or passive cooling o Deep hypothermia – 15-18 degrees - Provides cerebral protection

Answer 289

- Myocardial protection o Cardiac arrest in diastole to minimise metabolic activity during period of suboptimal perfusion o Cooling of heart – reduced O2 consumption and hence minimise ischamic risk - Facilitation of surgery o Immobile relaxed heart o Blood less field

Answer 290

**Cannula** - Direct vessel damage associated with cannulation - Embolic stroke by dislodging plaques with cannula **Solution** - Air bubbles in cardioplegic solution can cause air embolus in coronary arteries or systemic circulation with consequent ischaemia - Fluid overload * Haemodilution and anaemia - Post op electrolyte disturbance and consequent risk of arrhythmias **Infusion** - Myocardial oedema , haemorrhage and injury from high infusion pressures - Failure to get widespread perfusion of the myocardium with the cardioplegic solution so some areas will remain warm and active and hence at risk of ischaemia

Answer 291

naturally occuring glycosaminoglycan with molecular weight ranging from 3-30Kda Can be given as a drug either fractionated or unfractionated.

Answer 292

Binds antithrombin 3 to potentiate the breakdown of factor Xa and thrombin (II) LMWH - potentiates breakdown of Xa only

Answer 293

- Unfractionated has variable effects - Heparin induced thrombocytopenia - Hyperkalaemia - Hypotension – histamine release at hight doses - Heparin response varies in individuals and risk of heparin resistance

Answer 294

- Hypothermia - Haemodilution - Renal and liver dysfunction - Thrombotic disorders

Answer 295

Protamine sulphate - cationic protein binds to heparin and neutralises it

Answer 296

* Hypotension / haemodynamic instability – most common can be minor or severe * Pulmonary HTN - secondary to pulmonary HTN * Anaphylaxis * Unbound protamine inhibits platelet activity, adhesion and aggregation and so promotes bleeding

Answer 297

usually activated clotting time - point of care test

Answer 298

Kaolin or celite these are surface reactors

Answer 299

CPB uses an extracorporeal circuit which has an artificial surface which can activate the coagulation pathway. Thus anticoagulation is required to offset this effect and prevent clot formation and circuit failure

Answer 300

300-400 units / kg test ACT 3-8mins later - should be > 480seconds before starting CPB recheck every 15-30mins during CPB 1/3 of initial dose is given at 90 mins and then every 60mins

Answer 301

1mg/ 100units of heparin given given as infusion over 15-20 mins

Answer 302

* Dosing of protamine should be based on the heparin concentration * Should aim to give a protamine: heparin ratio of 0.6- 0.8 * If >1.3: 1 then risk of bleeding due to platelet dysfunction (from excess protamine) * If < 0.6 then bleeding risk due to excess heparin

Answer 303

inadequate response to heparin e.g. ACT low despite giving good dose of heparin. specifically defined as ACT < 480 seconds despite having given 300-400units/kg of heparin

Answer 304

Mostly ATIII deficiency * congenital – autosomal dominant * acquired – reduced synthesis ( liver failure, warfarin ), increased clearance (nephrotic syndrome, renal failure), DIC , pre op heparin use Increased heparin clearance Elevated heparin binding proteins – infective endocarditis / sepsis will increase protein load

Answer 305

* Repeat heparin doses - Risk of platelet dysfunction and heparin rebound * Supplement with ATIII - As FFP or recombinant ATIII concentrate * Give adjuvant anticoagulants if resistance persists e.g. bivalirudin

Answer 306

Some patients have residual heparin post op and are at risk of bleeding Caused by * incorrect protamine dose * Mismatch in clearance rates * Redistribution from fat/ protein stores

Answer 307

complication of heparin type 1 and 2 type 1 is non immune - mild and resolves upon discontinuation type 2 is an autoimmune thrombocytopenia caused by heparin. it Involves the formation of immune complexes between heparin, platelet factor 4 and IgG antibodies

Answer 308

type 1 = 2-3days type 2 = 5-14 days

Answer 309

* dose - > 32,000 units * timing - pre /post op continous infusion of CPB within last 100days * duration of infusion - more than 4 days * route - IV > SC * sex - femal > male * type of heparin - unfractionated

Answer 310

4 Ts - Thrombocytopenia - Timing of platelet fall - Thrombosis - Likelihood of other causes of thrombocytopenia Total of 8 points – if >/= 4 = high risk and needs further testing e.g. ELISA test – immunoassay for detecting auto antibodies

Answer 311

* Postpone non-urgent surgery until HIT resolves (typically after 100 days). * Other agents for urgent procedures. - Direct thrombin inhibitor – bivalirudin , argatroban * Or use of plasmapheresis to remove IgG antibodies until functional assay becomes negative

Answer 312

* No specific reversal agent * ACT non linear and less reliable * Prolonged effect in renal failure

Answer 313

- Autoantibodies that activate endothelial cells and platelets resulting in both arterial and venous thrombosis - More common in woman and associated with other autoimmunity e.g. lupus - can still use heparin but.. - Difficulty in monitoring as APTT and ACT are often elevated at baseline

Answer 314

- Should replace factors pre op - acts to normalise the in vitro tests of clotting used to monitor anticoagulation - Then heparin used as normal - TXA to reduce bleeding

Answer 315

- Administration error - Wrong drug given, Cannula not patent, Drug not flushed in - Pharmacokinetics - Increased protein binding e.g. malignancy, acute illness – heparin is heavily protein bound so any increase in plasma proteins will lower free drug level - Lack of anti thrombin 3 - Drug induced (recent heparin use) , Accelerated consumption (sepsis , DIC), Dilution ( CPB) , Decreased synthesis (liver disease) or Familial

Answer 316

- Sits within the orbit - Globe can be divided into 3 chambers = anterior, posterior and vitreous - Surrounded by 3 layers – sclera , choroid, retina

Answer 317

- V1 – trigeminal nerve , opthalmic branch – sensation to touch and pain - Optic nerve – visual sensation / light perception

Answer 318

- Anterior = limbus – corneoscleral junction - Posterior = dural sheath around the optic nerve

Answer 319

- Active secretion of aqueous humour by ciliary bodies - Passive secretion by ultrafiltration of aqueous humour influenced by starlings forces – blood pressure, intraocular pressure and plasma oncotic pressure - Drainage of aqueous humour via trabecular network and canal of Schlemm – balance between intraocular pressure and episcleral venous pressure

Answer 320

low risk so unless significant comorbidities usually no pre op assesment is needed. - Ix may be considered in higher-risk patients (ASA 3–4), such as assessing renal function or obtaining an ECG if not recently done. - Clotting profile within 24 hrs if patient on anticaog - Axial length measurements if patient having peribulbar or retrobulbar injection

Answer 321

usually not required as under locoregional

Answer 322

- Advantages o May aid glycaemic control in diabetic patients o Avoids discomfort, dehydration and nausea - Disadvantages o Risk of aspiration – although rare especially with locoregional techniques

Answer 323

>180 / 110 mmHg

Answer 324

- Endophthalmitis - Choroidal haemorrhage - Wound infections - Increased overall mortality

Answer 325

- Global Deterioration Scale (GDS) helps assess dementia severity and guide anaesthetic planning; regional techniques may be appropriate up to GDS stage 5.

Answer 326

locoregional +/- sedation GA

Answer 327

**- Surgical factors –** * length of time and how invasive o Corneal and conjunctival surgeries – topical anaesthesia e.g. minimal incision cataracts, removing foreign bodies o Deeper procedures – vitrio or retinal – regional blocks to keep eye still and ensure complete sensory blockade o Long proceedures or strange positioning – GA o the type and size of incision o the complexity of the procedure o the experience of the surgeon **- Patient factors ** o Cooperation o Anxiety – will they cope with surgical instruments coming towards their eye o Age – kids usually need GA o Globe length – increases risk of blebs called staphalo marta which can get punctured in regional proceedures o Allergy to local anaesthetic – cant do regional o Active significant eye infection – cant do regional **- Anaesthetic ** o Topical – cheap and easy but doesn’t stop eye from moving o Regional – less cheap, less quick , better pain relief and better reduction in movement o GA – most expensive and longest but may be needed for those who don’t tolerate o User choice – i..e anaesthetist experience and preference

Answer 328

* Improves comfort, anxiety and helps patients to remain still * If moderate / deep sedation then fasting may be required – associated with the disadvantages of fasting * Risk of loss of airway * Risk of aspiration

Answer 329

- Often have a lot of comorbidities / frail - Difficult to access airway - Airway can hinder surgeons - Coughing on tube can be disastrous for the eye – raised IOP - Less risk of aspiration - No need to fast - less risk of cognitive decline / delirium post op - increased turnover list – more expensive

Answer 330

o takes photos of eye and retina pre and intra operatively o conjunctival vessels are used as reference points o conjunctival haemorrhage will interfere with this. – hence do needle based blocks after the pictures are taken.

Answer 331

o Used to maintain pupil dilation and prevent floppy iris syndrome. o However, systemic absorption (nasolacrimal ducts and conjunctival veins) - can cause cardiovascular side effects, o necessitating patient monitoring during surgery.

Answer 332

- Local technique: o Topical o Subconjunctival - Regional technique o Sub tenons - cannula technique o Peribulbar - needle technique o Retrobulbar - needle technique

Answer 333

Retrobulbar Block - Highest risk of globe perforation, brain stem anaesthesia, expulsive haemorrhage.

Answer 334

- Involves conjunctival dissection and cannula insertion into the sub-Tenon’s space, - Dissecting conjunctiva and tenons capsule with foreceps and scissors after anaesthetising with local anaesthetic first - Then insert blunt curved needle into subtennons space - Inject 2-5ml of LA fewer complications and bleeding risk - better for those on anticoag

Answer 335

- Chemosmosis – conjunctival swelling - Subconjunctival haemorrhage - Retrobulbar haematoma - Orbital haemorrhage and compression of optic nerve / central retinal artery – risk of blindness - Globe perforation - Neuroaxial LA spread and total spinal - Corneal abrasion - Allergies of LA or hyaluronidase

Answer 336

- Akinetic globe for surgery - Good analgesia - Good sensory block – reduces oculocardiac reflex by blocking afferent limb - Reduces need for GA and related complications e.g. in airway management - Blunt cannula so less risks from sharp needles and considered to be least painful of the techniques.

Answer 337

- Topical = 0.5 -1% tetracaine or 3.5% lidocaine or 0.5% proxymetacaine - Regional = lignocaine, bupivacaine, and ropivacaine. - A mix of lignocaine 2% (for fast onset) and bupivacaine 0.5% (for prolonged effect and analgesia) is frequently preferred.

Answer 338

Hyaluronidase - enhance tissue permeability, speed up onset, improve block quality, and reduce required LA volume

Answer 339

- Pain-Free Surgery - Facilitate the Surgical Procedure - akinesia (immobility of the eye) - Minimise the Risk of Systemic Complications (associated with GA ) , - Reduce the Risk of Surgical Complications By providing optimal anaesthetic conditions, the risk of intraoperative complications can be minimized.

Answer 340

- Patient refusal - LA anaphylaxis / allergy - Localised eye infection - Inability to cooperate e.g. anxiety, LD, dementia - Abnormal coagulation - Inability to lie flat due to MSK, resp, CVS conditions or significant cough - Globe perforation or trauma

Answer 341

Local - subconjunctival haemorrhage, chemososis Serious local - orbital haemorrhage globe perforation , nerve injury/ visual loss Systemic - brainstem anaesthesia , allergy , occulocardiac reflex

Answer 342

- Trigeminal vagal reflex causing bradycardia when the eye is stimulated - This can inturn cause significant hypotension - Afferent – opthalmic branch of trigemninal nerve V1 - Trigeminal sensory nucleus receives afferent and causes activation of vagus efferent - Efferent – vagus nerve

Answer 343

- Traction on extra ocular muscles e.g. for squint surgery – mainly medial rectus - Pressure on globe – hydrostatic pressure from injectate of regional anaesthetic technique, pressure applied to encourage spread of local, pressure applied by surgeon in surgery

Answer 344

- Age – more common in kids due to higher vagal tone - Type of surgery – strabismus or retinal detachment - Anaesthesia depth – more pronounced in light plane

Answer 345

- Risk of infection to eye – endophthalmitis - Risk of extrusion of vitreous humour through penetrating injury – increased risk from raised intraocular pressure - Visual loss - Retinal detachment

Answer 346

- Avoid certain drugs = suxamethonium and ketamine - Minimise sympathetic activation – good analgesia - Normal CO2 and O2 - Ensure adequate depth of anaesthesia and good analgesia - Good paralysis – optimises relaxation of extraocular muscles and ventilator synchrony - Deep extubation / remifentanil – reduces coughing - Good antiemetic cover to reduce PONV - Positioning – avoid tube ties, head in neutral and slight head up - Can use acetazolamide and mannitol in specific cases

Answer 347

minimally invasive surgical procedure that involves cutting, clipping, or destroying part of the sympathetic nerve chain in the thoracic (chest) area. Used to treat hyperhiderosis, raynauds, flushing, CRPS

Answer 348

hyperhidrosis - palmar, craniofacial or axilary cardiac - congential long QT, angina pectoris pain - raynauds, complex regional pain syndrome other - facial flushing

Answer 349

Preganglionic - short, ACh, originate from lateral horn or T1 to L2/3 post ganglionic - from sympathetic chain, long, NA

Answer 350

superior, inferior and middle cervical ganglia some from stellate ganglia

Answer 351

fusion of inferior cervical ganglia and 1st thoracic ganglia supplies head and neck, arms, heart

Answer 352

- head up with arms abducted - blind insertion of endoscope between 4th and 5th intercostal space, mid axillary line - inflate space with gas (CO2 inflation) - 2nd post introduced under vision into 2nd/3rd intercostal pace - Identify sympathetic chain - Resection / laser coagulation / clipping at level depending on indication

Answer 353

- T2-3 for palmar hyperhidrosis - T2-4 for axillary hyperhidrosis - T2-4/5 for angina / long QT

Answer 354

usually young and fit patients but may need detailed CVS history if having proceedure for cardiac reason. G+S - risk of bleed good IV access - in case of bleeding arterial line - risk of hypotension (capnothorax) and bleeding may be using one lung ventilation or can use 2 lungs with thoracic inflation = degree of shunting and hypoxia

Answer 355

AIRWAY o Malposition of double lumen tube or bronchial blocker – hypoxia RESP o Tension pneumothorax – related to thoracic insufflation o One lung ventilation – shunting, atelectasis , hypoxia. Especially Bilateral surgery – significant atelectasis of first deflated lung may lead to significant hypoxia when operating on second side. Can extend post op - Risk of acute lung injury in the days to follow – especially in those who did not have one lung ventilation CVS: o hypotension from capnothorax – CO2 gas in pleural space can increase thoracic pressures and impede venous return and hence cardiac output. o Cardiac arrhythmia induced by intrathoracic diathermy o Bleeding requiring thoracotomy – subclavian, intercostals - Chest pain in immediate post op period Other o Surgical emphysema - Horners syndrome - Compensatory sweating else

Answer 356

- Usually supine, reverse Trendelenburg , arms abducted o Risk of brachial plexus injury - Sometimes prone o Risk of eye damage, airway dislodgement - Sometimes lateral o Difficulty with ventilation, dislodgement of airway, common peroneal nerve pressure damage.

Answer 357

**Absolute** o Isolation of diseased lung to prevent contamination of healthy lung e.g. empyema , massive haemorrhage o To control distribution of ventilation and prevent ventilation of lung areas with large air leaks e.g. bronchopleural fistula, major cyst or bullous disease or traumatic bronchial injury o Unilateral lung lavage for treatment of cystic fibrosis **Relative** o To facilitate thoracic surgery – lobectomy, pneumonectomy, endoscopic thoracic surgery. o Oesophagectomy o Mediastinal mass surgery o spinal surgery in lateral position. The above can also be categorised into those facilitating surgery (relative) and those for therapeutic procedures (absolute)

Answer 358

double lumen tube bronchial blocker standard ET tube advanced endobronchially

Answer 359

- most definitive - has a tracheal outlet which allows option of ventilating either lung as well as accessing non dependant lung for suction/ CPAP - larger size / bulky so can be traumatic and make insertion difficult - more difficult to insert in a difficult airway - need to change ETT prior to transfer if they are to remain ventilated - risk of movement/dislodgement can result in failure to isolate

Answer 360

- Can be inserted via existing tube or tracheostomy – good for difficult airways - Doesn’t require tube change for post op ventilation - More likely to migrate intraoperatively especially on repositioning – must always confirm with bronchoscope - Cant apply suction or CPAP to non dependant lung

Answer 361

- Simplest technique, no special equipment needed - Good for emergencies - no need to tube change however - No access to non dependant lung for suction or cpap - Non dependant lung collapse is unpredictable

Answer 362

auscultation fibreoptic scope

Answer 363

- Left sided – most surgeries can use these and they are easier to insert

Answer 364

- Surgery involving left main bronchus e.g. left pneumonectomy or lung transplant or left tracheobronchial disruption - Distortion of normal left main bronchus anatomy e.g. tumour compressing left main bronchus

Answer 365

A degree of hypoxia is expected after one lung ventilation and often subsequently improves due to hypoxic vasoconstriction. - Increase FiO2 - Call for help / alert team - - AIRWAY: o Take over to manual ventilation to assess compliance o check circuit connections and anaesthetic machine o Check position of double lumen tube – fibreoptic scope o Suction catheter – unblock secretions in tube - BREATHING: o Look at capnography and sats o Auscultate the chest – bronchospasm? o insufflate the non ventilated lung using suction catheter o PEEP to ventilated lung (may worsen shunt) o Apply some CPAP to non ventilated lung – to help V:Q mismatch o Intermittent inflation of collapsed lung - CIRCULATION o Optimise haemodynamic parameters – fluids / vasopressors o Clamp appropriate pulmonary artery – reduces shunt – only for pneumonectomies - If very severe, may need to resume b/l ventilation

Answer 366

applying PEEP to dependant lung - can worsen perfusion to this lung, worsening the shunt fraction Adding oxygen or CPAP to non ventilated side with suction catheter – reduce hypoxic vasoconstriction worsening shunt

Answer 367

- Assess risk of post op dyspnoea o Lung function tests o Predicted post op FEV1 and DLCO based on pre op measurements and amount of lung segments removed - Functional assessment e.g. CPET – VO2 peak most useful measure o < 10ml O2/kg/min – contraindicated for pneumectomy o > 20 mlO2/kg /min = safe o > 15 = good reserve - Specific mortality prediction scores e.g. RESECT 90 and Thoracoscore – age, sex, comorbidities, symptoms etc - ECHO for pre existing pulmonary HTN – this will be worsened by having half the pulmonary vasculature after pneumonectomy

Answer 368

- Mechanical o Double lumen tube is narrower than standard ET o Double lumen more easily obstructed with secretions due to narrowness o Malposition results in loss of airway patency o Inappropriate ventilation – high volumes for just one lung - Patient o Atelectasis of ventilated lung o Pre existing lung disease o Obesity o Failure to muscle relax / ventilator dysynchrony - Acute events o Pneumothorax o Anaphylaxis o Bronchospasm

Answer 369

infection of the endothelium of the heart causing a severe multisystem disease that often re quires cardiac surgery.

Answer 370

* Staphylococci – now the leading cause. Associated with health care infections and IVDU * streptococci – e.g. viridans – subacute, linked to oral cavity in those with pre existing heart condition * Enterococci faecalis – associated with urinary and GI procedures others - MRSA, fungal, strept bovis (GI malignancy),

Answer 371

cardiac: bicuspid AV, rheumatic disease, CHD, previous I.E, implanted cardiac device, prosthetic valve non cardiac - IVDU, haemodialysis, malignancy, >65yrs, poorly controlled diabetes, immunocompromised, long term venous devices

Answer 372

x2 more common in men

Answer 373

Endothelial damage triggers platelet aggregation and clotting, forming sterile vegetations that can become infected during bacteraemia. vegetations form upstream of blood flow e.g. on ventricle side of aortic valve.

Answer 374

mitral, then aortic, then tricuspid, then pulmonary

Answer 375

**Cardiac complications:** * o Valve damage can result in Regurgitation and hence heart failure, pulmonary oedema and shock. * o Aortic root abscess – AV block * o Perivalvular abscess and fistula formation * o AF **Sepsis and Persistent infection** **septic embolism** o brain - stroke , liver , spleen, limbs **AKI is common**

Answer 376

* can be acute or subacute (milder) * Night sweats, fever , weight loss , fatigue * Murmur * Sepsis + associated complications * Clinical signs - Janeway, oslers nodes, splinter haemorrhage- rare * Other features may include glomerulonephritis, anaemia, splenomegaly * Cardiac - pulmonary oedema, cardiogenic shock * Neuro – confusion , cognitive changes * Septic emboli may affect various organs, including the brain, liver, kidneys, and spine.

Answer 377

Dukes criteria - looks at clinical signs, blood cultures and echocardiogram findings. major criteria = positive BC from typical organisms on 2 samples OR ECHO/CT evidence e.g. vegetation, abscess, new prosthetic valve lesion. minor criteria = predisposing factor, fever >39, valvular phenomena (emboli, splenic infarction, mycotic aneurysm, janeway, intracranial haemorrhage), immunological phenomena (oslers, roth spots, positive rheumatoid factor), microbiological evidence but not part of major. need: 2 major, 1 major and 3 minor or 5 minor.

Answer 378

- MDT approach – infectious diseases, cardiologist, critical care, neurology, nephrology, surgeons - A to E - IV Abx – after cultures – for 4-6 weeks o Choice depends on valve, patient, allergies and micro results use local Abx guidelines

Answer 379

* Infected prosthetic material * Severe valve regurgitation * Uncontrolled infection * High embolic risk * Large vegetations: >10 mm post-embolism or with valve dysfunction, or isolated vegetations >15 mm (urgent) / >30 mm (very large)

Answer 380

PRE OP: optimise before surgery * Assess for complications - renal function, embolic events and heart failure * renal function optimised with fluids, electrolyte replacement, RRT * ensure effective Abx at correct dose * manage any heart failure with ionotropes * treat arrhythmias * correct coagulapathy * ensure adequate imaging - TOE to look at vegetations etc and cardiac function Intra op - as standard plus... - arterial line - central venous access - Continuous TOE is valuable for real-time assessment of cardiac function and surgical repair efficacy. - maintain haemodynamic stability (vasopressors, ionotropes) guided by cardiac output monitoring post op - ITU - continue Abx and organ support

Answer 381

Only in v. high-risk individuals undergoing certain medical or dental procedures that might introduce bacteria into the bloodstream. high-risk patients: - Previous endocarditis - Valve replacements - unrepaired CHD Otherwise prioritize preventive care—like good oral hygiene, regular dental check-ups, and aseptic technique

Answer 382

oral amoxicillin - first line clindamycin (pen allergy)

Answer 383

patient factors - age, prosthetic valve, diabetes clinical features - stroke, shock, heart/renal failure micro - S.aureus, fungal, non HACEK gram neg Echo - severe regurg, abscess, large vegetation, low EF

Answer 384

- Invasive BP monitoring - Consider TOE and cardiac output monitoring

Answer 385

superficial - sub cut fat, lymph nodes, platysmas deep = investing fascia, pre vertebral, pre tracheal, carotid sheath investing fascia = sternocleidomastoid + trapezius pre vertebral = vertebrae, deep neck muscles, scalene, sympathetic trunk pre trachea = trachea, oesophagus, thyroid/ parathyroid + recurrent laryngeal n carotid sheath - carotid vessles, vagus, IJV

Answer 386

anterior rami of C1-4

Answer 387

motor (deep) = hypoglossal , nerve to geniohyoid, nerve to thyrohyoid, phrenic nerve and ansa cervicalis sensory: o Greater auricular – C2/3 – skin over parotid, ear and angle of jaw o Lesser occipital – C2 – skin behind ear o Transverse cervical – C2/3 – skin of anterior neck o Supraclavicular – C3/4 – skin over clavicle, shoulder and upper chest

Answer 388

thyroid surgery - pain relief , usually with GA awake carotid endartectomy clavicle fractures / surgery - alongside supraclav or interscalene block superficial surgery - cervical lymph node resection or IJV cannulation

Answer 389

- Superficial – o Infection o haematoma (external jugular) o intravascular injection o Nerve injury - Deep – same as above but increased risk o additional risks of nerve injury to phrenic , vagus, hypoglossal and recurrent laryngeal nerves. o Higher haematoma risk with deep (carotid and internal jugular) o Risk of subarachnoid injection o Sympathetic blockade and horners - common

Answer 390

bronchial cancer traumatic injury with uncontrolled haemorrhage infective disorders - chronic TB, fungal, abcescc/empyema inflammatory lung disease

Answer 391

standard pre op PLUS thoracoscore - exercise tolerance and physical reserve lung function tests - ppoFEV1 and ppoDLCO exercise function - shuttle walk test / CPET ECHO routine bloods + ECG + CT imaging

Answer 392

ppoFEV1 = predicted post op FEV1 = pre op FEV1 x fraction of remaining lung segments ppoDLCO = transfer factor - predicts difusion / gas exchange capacity these predict the likelihood of post op dyspnoea and need for LTOT if >60% - low risk, no further Ix 30-60% - shuttle walk test < 30% - high risk , more likely to need CPET

Answer 393

VO2 peak < 10 ml/kg/min - contraindicated > 20 = safe

Answer 394

- Not suitable based on physiological testing e.g. LFT < 30% predicted OR CPET VO2 peak < 10mO2/kg/min - Pre existing pulmonary HTN - Severe valvular disease or poor ventricular function - Metastatic disease – subdiaphragmatic extension or nodes in contralateral lung

Answer 395

- Stop smoking - Physical exercise training to improve lung function and muscle mass - Nutritional optimisation - Management of anaemia - Optimise comorbidities – HF, diabetes, COPD

Answer 396

**Pre induction** o ICU bed ready o Cross match 2 units **induction** o AABGI + skilled assistance + airway o Invasive monitoring **Airway:** o Double lumen tube - Check with fibreoptic scope and auscultation **breathing** - one lung ventilation **CVS** o Fluid restriction – avoid pulmonary oedema o Treat hypotension with vasopressors not fluids **other** - Positioning – lateral decubitus (lying on side) - Clamp testing: Before lung removed, test clamp of pulmonary artery . Watch for sings of RV failure – CVP rise, collapse **post op** - Analgesia – epidural or paravertebral catheter

Answer 397

- Cardiac arrhythmias o Very common – AF, flutter, SVT - Pulmonary HTN with progressive right heart failure - Post pneumonectomy pulmonary oedema - Nerve damage – phrenic / recurrent laryngeal - Bronchopulmonary fistula o Abnormal connection between bronchial tree and pleural space. Due to breakdown of bronchial stump - Cardiac herniation

Answer 398

This may require either flexible or rigid bronchoscope. flexible = topicalisation +/- sedation + LMA/ET/SV rigid = GA + no definitive airway (jet vent, high flow, SV). usually TIVA but can use volatiles intermittently

Answer 399

**AIRWAY** o Risk of difficult airway / obstruction secondary to pathology – careful hx , examination, imaging. MDT planning o Shared airway surgery o no option for secure airway - aspiration, method for ventilating - **- CVS** o Stimulating procedure – need patient deep – potential instability o Potential for gas trapping, high thoracic pressures and drop in CO **- Depth of anaesthesia** o Volatiles are not predictable – intermittent o TIVA usually better

Answer 400

- High frequency jet ventilation attached to port e.g. monsoon - Manual low frequency jet ventilation – sauders manual jet - Controlled ventilation via anaesthetic circuit attached to a 22mm side port of bronchoscope. - High flow nasal oxygen with apnoeic oxygenation - ECMO – infrequently used but an option

Answer 401

- Not sealed – a lot of leaks - Cant use oxygen during laser so pauses in ventilation - Disrupted through passing tools via bronchoscope - Leak means a lot of theatre pollution if using volatiles and less reliable GA.

Answer 402

- Diagnostic – o biopsy of lesion o inspection of tracheobronchial lesions e.g. difficult airway - therapeutic o tumour resection o stenting airway o removing foreign body

Answer 403

- barotrauma associated with jet ventilation – pneumothorax, pneumomediastinum, sub cut emphysema - inadequate gas exchange – hypercapnoea, hypoxia - awareness – inadequate anaesthesia due to intermittent volatile administration - airway contamination – ventilation without airway protection / cuff - laryngospasm / bronchospasm - cardiac instability from gas trapping and high thoracic pressure

Answer 404

- soft tissue trauma – lips, tongue, vocal cords , trachea. may cause airway oedema and compromise - dental damage - major haemorrhage associated with tissue damage / resection of lesion - pneumothorax due to resection or biopsy - C spine damage from movements perioperatively esp in RA

Answer 405

- Airway topicalization – however doesn’t get carina effectively and residual effects post op may affect airway reflexes - NMBA - Remifentanil infusion – not as profound paralysis, but no residual effects

Answer 406

patient = FiO2 as low as possible < 0.3, special laser resistant tubes (double cuff), goggles, saline soaked gauze, dont use N20 staff /general = signs on doors, close blinds, non reflective equiptment, laser safety officer, goggles

Answer 407

arrhythmias bleeding tamponade pulmonary HTN neurological - delirium, cognitive dysfunction, stroke

Answer 408

post op cognitive dysfunction - subtle persistent decline in cognition function e.g. memroy, concentration delirium - acute and fluctating stroke - ischaemic, embolic, haemorrhagic ischaemic spinal cord injury TIA

Answer 409

- Brachial plexus injury – CVC insertion, positioning , internal mammary artery harvesting - Ulnar nerve injury – during radial artery harvesting - Phrenic nerve injury – during internal mammary artery harvesting - Recurrent laryngeal nerve injury – intubation or IMA harvesting - Saphenous nerve – if using saphenous vein harvesting

Answer 410

- Pre operative dementia – alzeihmers, parkinsons , vascular dementia - Pre existing cerebrovascular disease / Hx of stroke - Age - HTN - Diabetes - Carotid stenosis

Answer 411

* duration of surgery * use of bypass - anticoagulation, microemboli from circuit, rapid rewarming resulting in cerebral oedema * bleeding - poor cerebral perfusion * microemboli from aorta during handling e.g. clamping

Answer 412

- Prolonged deep hypnotic time e.g. high level of burst suppression - Low MAP and poor cerebral perfusion

Answer 413

- Surgical: o Minimally invasive techniques – reduces stress response o Use of USS to check aortic plaques before handling o Adequate priming of CPB circuit if used – embolus filters, bubble traps - Anaesthetic: o Good maintenance of haemodynamic stability – arterial monitoring and vasopressors o Careful anticoagulation monitoring and management o Avoid excess anaesthesia – use of BIS o Normalise physiological parameters – glucose monitoring, acid base balance, correct electrolytes o Avoid fast rewarming to prevent cerebral oedema o Use of cerebral regional oximetry

Answer 414

- BECKS TRIAD – hypotension, muffled heart sounds, raised JVP others.. - - Tachycardia - Breathlessness - Chest pain - Pericardial rub - Pulsus paradox - Kussmaul sign

Answer 415

exagerrated drop in BP with inspiration > 10mmHg seen in tamponade

Answer 416

o Rise / lack of fall of JVP with inspiration seen in tamponade

Answer 417

acute haemorrhage - trauma, type A dissection, iatrogenic following interventional cardiology proceedures. post cardiac surgery viral / infective non infective - autoimmune, malignant, uraemia

Answer 418

o Pericardial effusions – fluid around heart in pericardial sac - >20mm considered significant o Collapse of cardiac chambers o IVC dilation due to right heart compression o Left shift of intraventricular septum during spontaneous ventilation o Swinging heart – heart is suspended within the fluid of pericardium so it can appear as if it swings as it contracts

Answer 419

o Enlarged globular appearance of the cardiac silhouette o Evidence of heart failure / pulmonary oedema

Answer 420

o Sinus tachycardia o Low voltage QRS complexes (attenuated signals due to fluid) o Electrical alternans – beat to beat variation in QRS amplitude o Atrial arrhythmias

Answer 421

o Raised pulmonary capillary wedge pressure

Answer 422

pericardiocentesis urgent cardiothoracic review - may requires pericardiotomy

Answer 423

- Subxiphoid = 1-2 cm inferior to the left xiphochrondal junction - Parasternal = 5th left intercostal space close to sternal margin - Apical – 1-2cm lateral to apex bear within 5th,6th or 7th intercostal space

Answer 424

- Pneumothorax - Laceration of the ventricle, coronary vessel or intercostal vessels = haemorrhage - Puncture of abdominal viscera / peritoneal cavity - Arrhythmias - Pneumopericardium - Pericardial depression syndrome – left ventricular dysfunction resulting in pulmonary oedema or cardiogenic shock

Answer 425

fast , full and tight o Maintain preload – replace lost volume o Maintain sinus rhythm – arrhythmias reduce CO further o Avoid bradycardia – stroke volume is limited and thus CO driven by rate o Maintain SVR – maintains filling of coronary vessels – use vasopressors and avoid vasodilators (MAP = SVR x CO – CO limited, so cant afford to drop SVR) o Maintain cardiac contractility – avoid cardiac depressants

Answer 426

VF bleeding cardiac tamponade

Answer 427

same approach but if no reversible causes found after 1 cycle then immediate chest re-sternotomy. no time for skin prep / theatre

Answer 428

- Myocardial disorder whereby the heart muscle is structurally and functionally abnormal. - That cannot be explained by coronary artery disease, HTN, valvular disease or congenital heart disease - They may be genetic or acquired

Answer 429

- Dilated cardiomyopathy – systolic dysfunction - Hypertrophic cardiomyopathy - diastolic dysfunction - Restrictive cardiomyopathy – impaired ventricular filling - Arrhythmogenic right ventricular cardiomyopathy- fibrofatty replacement of RV myocardium - Unclassified

Answer 430

* LV dilation * inability for actin/myosin to overlap efficiently * systolic dysfunction * dilation can also result in valvular disease * overall HF * embolic complications due to inefficient systole * Increased volume within heart also increases diastolic pressures and thus impedes coronary blood flow and oxygenation

Answer 431

- Often idiopathic - Familial – e.g. genetic causes such as Duchenne’s and Becker muscular dystrophy - Post viral myocarditis - Drugs e.g. chemotherapy , alcohol - Pregnancy - Nutritional deficiencies

Answer 432

- Signs and symptoms of HF – SoB, poor exercise tolerance, fatigue, ascites, peripheral oedema - Arrhythmias - Embolic events - Sudden death

Answer 433

- Medical management of heart failure - Beta blockers , Diuretics , ACE inhibitors / ARBs, Anticoagulants , SGLT2 inhibitors - Cardiac devices o Cardiac resynchronisation pacing therapy o Implantable cardiac defibrillator o LV assist device - Surgical o Partial left ventriculectomy o May require heart transplant

Answer 434

EF < 20% LV hypkinesia non -sustained VT elevated LV end diastolic pressure

Answer 435

- Maintain sinus rhythm - Adequate volume loading / pre load - Maintain normal SVR o prevent increases in afterload o Prevent sudden hypotension – poor coronary perfusion - Avoid myocardial depression – may require ionotropes

Answer 436

- If possible regional and avoid GA – best for haemodynamic stability - Awake arterial line - Slow IV induction – impaired circulation – avoids overdosing and excessive myocardial depression/ drop in SVR - Increase opioids on induction to reduce amount of propofol needed - Balanced maintenance anaesthesia and use BIS to avoid too much myocardial depression with volatiles

Answer 437

- Transoesophageal ECHO – dynamic assessment of heart filling and cardiac output - Oesophageal doppler – SV assessment - Invasive arterial blood pressure monitoring – stoke volume variation, acid base balance via frequent blood sampling , beat to beat blood pressure to have tighter control - Depth of anaesthesia monitoring to reduce amount given - Cerebral oxygenation monitoring – reduce risk of post op cognitive dysfunction

Answer 438

autosomal dominant

Answer 439

- Complex genetic condition with potential environmental interaction. - Myocardial cells are replaced by fibrous tissue - These abnormal myocardial cells may form re-entry electrical circuits with bundle branch block and subsequent arrhythmias - Progresses to regional wall motion abnormalities and right heart failure

Answer 440

* a spectrum of clinical presentations characterised by organ hypoperfusion and tissue hypoxia caused by cardiac dysfunction * persistent hypotension - systolic BP < 80-90 mmHg or MAP < 30 * Cardiac index - < 1.8 L/ min /m2 unsupported with adequate filling pressures (LVEDP) OR clinical parameters * * Systolic BP < 80-90 plus * Clinical signs of hypoperfusion e.g. cool peripheries, confusion , olgiouria * Lab signs - e.g acidosis, lactic acid, high creatinine

Answer 441

- Acute myocardial infarction (AMI) with resulting left ventricular (LV) dysfunction is the main cause of cardiogenic shock - Most commonly LAD and then RCA and left circumflex o Starts with thrombotic occlusion of a coronary artery leading to myocardial ischaemia, infarction - Reduced contractility results and hence lower CO and lower arterial pressure - This raises LV end-diastolic pressure (LVEDP) o worsens coronary perfusion, o causes pulmonary congestion and hypoxaemia * More than just “pump failure” o neurohormonal activation (RAAS and sympathetic) o leading to vasoconstriction, fluid retention, tissue hypoperfusion, and congestion. o These changes create a vicious cycle of worsening myocardial function and circulatory collapse.

Answer 442

- Wet and cold – Classic type = reduced CO, high SVR and high wedge pressure - Cold and dry - where capillary pulmonary wedge pressure is normal - wet and warm - where SVR is low

Answer 443

* Only way to improve outcome = Myocardial reperfusion by revascularisation o Mostly by PCI o Surgical revascularisation is reserved for cases where PCI is not feasible or complications occur. * Surgery is also the main treatment for mechanical complications (e.g., acute severe mitral regurgitation or ventricular septal rupture). * Where possible, patients are stabilised with mechanical circulatory support e.g. intra-aortic balloon pump (IABP) or VA-ECMO before surgery to improve outcomes

Answer 444

sustained hypotension caused by pathological vasodilation in combination with increased vasopressor requirements, capillary leak and tissue hypoperfusion

Answer 445

- Septic shock – - Cardiac surgery with cardiopulmonary bypass - Trauma & burns - Pancreatitis - Neuraxial anaesthesia - Spinal cord injury

Answer 446

fluid - resusitation vasopressors - multimodel e.g. noradrenaline and vasopressin

Answer 447

vascular surgical procedure to remove atheromatous plaques from the carotid artery to reduce the risk of stroke

Answer 448

patients who have had a stroke / TIA will recieve a carotid doppler exam and if they have moderate / severe stenosis (50-99%) of carotid artery then they should be referred for carotid endartectomy within 24 hours and have the proceedure within 2 weeks

Answer 449

50-69% = moderate 70-99% = severe

Answer 450

**Ischaemic – majority ** o Cerebral vascular disease – atherosclerosis within cerebral vasculature o Embolization (Atherosclerotic plaques – carotid artery OR AF ) o Systemic hypoperfusion – profound hypotension **Haemorrhagic ** o HTN o Berry aneurysm o AV malformation

Answer 451

- Age - Smoking - Diabetes - Hypercholesterolemia - HTN - Family Hx - AF

Answer 452

expose carotids cross clamp above and below area of stenosis (heparin given just prior to this may or may not use a shunt vertical incision atheroma removed defect closed by primary closure or using a patch (patch reduces risk of restenosis) (shunt from below clamp to above clamp)

Answer 453

**- GA ** **- Local / regional = ** o Local anaesthetic infiltration o superficial cervical plexus block o deep cervical plexus block o combined superficial and deep o intermediate plexus block o Cervical epidural – rare in UK

Answer 454

stoke bleeding periop MI infection cranial nerve injury - superior laryngeal, recurrent laryngeal, hypoglossal cerebral hyperperfusion syndrome

Answer 455

immobility no anxiety / agitation controlled ventilation potential for neuroprotection

Answer 456

lack of direct neurological monitoring - increased need for a shunt and complications associated intraop hypotension from GA delayed recovery from GA may mask some neurological complications

Answer 457

awake patient allows real time neurological monitoring Reduces shunt rate closure of wound at physiological BP - reduces haemotoma risk avoids need for airway - haemodynamic changes with laryngoscopy/ extubation. And risks of ET tube from sore throat to cant intubate monitoring post op is improved as not recovering from GA reduced hospital / ITU stay

Answer 458

risk of movement / agitation pain / anxiety can increase risk of MI risk associated with over sedation - need to convert to GA and limited access to airway risk associated with LA = LAST, allergy risk associated with needling = subachnoid injection, nerve damage (phrenic , recurrent laryngeal ) , infection, haematoma

Answer 459

- Carotid artery stump pressure - Transcranial doppler USS – use middle cerebral artery - Near infra red spectroscopy - EEG - Jugular venous O2 sats

Answer 460

- Dysregulated state of cerebral blood flow following restoration of arterial blood flow to the brain after carotid endartectomy - - Clinical triad o Severe ipsilateral headache o Seizures o Focal neurology = hemiplegia, neglect, hemianopia, aphasia - Accompanied by post op HTN in almost all patients - Can occur up to 1 month after but usually in first 5 days

Answer 461

- HTN - High grade stenosis - Contralateral carotid stenosis - Recent contralateral carotid endarterectomy

Answer 462

**- Anaesthetic** o GA – reduced SVR and myocardial depression o Pain and stress response and agitation – tachycardia / hypertension o LAST **- Surgical** o Bleeding o Carotid baroreceptors - Damage to fibres during surgical incision or removal of plaques = results in hypertension OR Compression of barorecptors – bradycardia o Cross clamp and cerebral hypoperfusion - Sympathetic response to increase BP and Reverse happens when clamp released o Surgical manipulation of vagus nerve – bradycardia and hypotension **- Patient factors** o Likely to have other CVS comorbidities and at risk of CVS events leading to haemodynamic instability

Answer 463

**- Embolic (biggest risk)** o Avoid shunts where possible o Careful surgical technique to avoid thromboembolism or air embolism when shunts used o Perioperative antiplatelet – DAPT o Heparin before cross clamping -**Ischaemic** o Use of shunt if collateral circulation is inadequate o Pharmacological management of intra op hypotension - **Haemorrhagic** o Pharmacological management of perioperative HTNe

Answer 464

cerebral hyperperfusion syndrome stroke carotid dissection or re-stenosis hypoxia from haematoma compressing airway normal causes of delirium - retention, opioids etc

Answer 465

- Localised dilation of abdominal aorta >3cm in diameter

Answer 466

- Repair is indicated when risk of rupture exceeds perioperative risk of surgery and this is when the diameter exceeds 5.5cm

Answer 467

EVAR open surgical repair

Answer 468

endovascular aneurysmal repair performed by vascular surgeon and interventional radiologist - Vascular surgeon exposes femoral arteries under local anaesthesia - Angiogram of aorta to determine the anatomy - Stent deployed across the aneurysm preventing blood flow into the aneurysm sac (which will eventually thromboses)

Answer 469

GA regional - epidural/spinal local

Answer 470

o IV heparin 5000 IU after femoral arteries exposed. o Target ACT = >200-250 seconds o Reversal with heparin may be required at the end of the procedure

Answer 471

**short term** - bleeding - aneurysm rupture, aortic dissection - Failed EVAR deployment – usually requires conversion to open and GA - AKI - Embolisation - ischaemia - bowel, spinal cord, lower limbs **long term** - endoleak - migration of graft - graft infection

Answer 472

Age high BMI pre op dehydration comorbidities - diabetes - cardiac failure - liver disease - eGFR < 60 pre op - HTN - periop diuretics

Answer 473

- Embolization of atheroma into renal arteries - Obstruction / damage to renal arteries by stent deployment – esp more common in fenestrated and branched EVARs - Surgical complications resulting in bleeding and hypotension - Ischaemia and then reperfusion of lower limbs resulting in inflammatory response – the longer the surgery / ischaemia time the more likely - Complex / prolonged surgery needing high contrast load.

Answer 474

- Prevent periop dehydration - Maintain good MAP - Limit IV contrast dose - Omit nephrotoxins – - Meticulous surgical technique to avoid embolization of plaques

Answer 475

overall open repair has more intraop risk associated with haemodynamic instability, bleeding risk, metabolic derrangements, longer operating time, need for intubation and IPPV, prolonged recovery and pain HOWEVER better long term outcomes and fewer longer term complications. therefore reserved for younger , less frail, less comorbid patients

Answer 476

**Minimally invasive** - avoids aortic cross clamping and hence haemodynamic /metabolic consequences – better for frail/ Co morbid patients **can to do it under local / neuraxial** - No need to intubate and IPPV - good for those with lung disease **Other benefits:** - Shorter duration - Less blood loss - Less post op pain – avoids large abdominal wound. Hence less complications associated with pain (pneumonia, opioid use) - Quicker recovery – early mobilisation (reduces DVT risk, muscle wasting and deconditioning and pneumonia) **More suitable for infrarenal aneurysms**– more straightforward so less operating time so EVAR /local anaesthetic more tolerable

Answer 477

**Increased afterload of LV** HTN, Increased wall tension & myocardia ischaemia **Loss of venous capacitance of distal part of body** o increase in central circulating volume – risk of pulmonary oedema and raised intracranial pressure **impaired blood flow distal to cross clamp**. risk of mesenteric, hepatic, renal , lower limb and spinal cord ischaemia **embolization of atheroma by clamp**

Answer 478

- deepening anaesthesia to allow vasodilation in upper circulation - use of vasodilators – e.g. GTN - anticoagulation with heparin prior to cross clamp – prevents thrombosis - good gas exchange and oxygenation delivery to myocardium to help increased O2 demand - avoid sitting clamp in area of a lot of plaques

Answer 479

- sudden and profound reduction in afterload - release of ischaemic metabolites after reperfusion of lower body – vasodilation and myocardial depression - venous capacitance increased – relative hypovolaemia – reduces preload/ venous return - drop in SVR and MAP will result in drop in myocardial perfusion – risk of ischaemia, failure, arrest

Answer 480

- gradual release of cross clamp with brief reapplication if necessary - adequate intravascular filling prior to release - use of vasopressors/ ionotropes ready - stop vasodilatory infusions / ensure depth of anaestheia is normal - treat any electrolyte disturbances, hypercapnia prior to release – maintain cardiac contractility

Answer 481

- Partial left heart bypass – cannulation of left atrium or pulmonary vein and return cannula into distal aorta. No oxygenation function needed just pump - Gott shunt – cannula connecting proximal and distal aorta - Partial femoro-femoral bypass = cannula into femoral vein – bypass machine (with or without oxygenation), return canula to femoral artery

Answer 482

- Spinal drain = minimise CSF < 15mmHg - Maintain MAP with adequate volume and vasopressors - Lowest possible site for clamp to minimise clamping above significant segmental arteries - Minimise clamp time - Sequential clamping of aorta with neurophysiological monitoring to detect which segmental arteries are significant

Answer 483

- Loss of elastic fibres + smooth muscle fibres in wall of artery - High pressures overtime cause weakening - Main cause is atherosclerosis - But also can be caused by marfans and some infections e.g. TB

Answer 484

- > 65yrs - Male - Smokers - HTN - Hypercholesterolemia - Family Hx of AAA - PVD

Answer 485

- Abdo +/- back pack pain - Hypotension - Tachycardia - Syncope - Palpable pulsatile mass abdomen

Answer 486

**A to E** - resusitation and major haemorrhage (1:1:1 ratio of RBC: Platelets : FFP) - AMPLE hx - arterial line while waiting -**Consent** o Explanation and need for ITU o Discussion of high risk with patient and families **Organisation / prepare for theatre** o Tell theatres o Communication with ODP to plan anaesthetic management and monitoring o Consultant vascular surgeon and consultant anaesthetist o Inform radiology o Arrange ITU bed

Answer 487

**Preparation:** o Induction in theatre, on table with surgeon scrubbed – reduce time between induction and aortic cross clamp o Set up blood infusion + cell salvage + rapid infuser (belmont) o AABGI monitoring + arterial line + catheter **Induction** o Modified RSI – alfent, prop/ket, sux/roc **Maintenance ** o Regular ABG / ROTEM o Cell salvage / blood management o Insert central line o Maintain normothermia o managmenet of cross clamping physiological changes and reperfusion **- post op ** o ITU – level 3 o Observe for complications

Answer 488

- bleeding anastomoses - Abdominal compartment syndrome - AKI - bowel ischaemia - lower limb ischaemia – due to distal dislodgement of thrombus - Embolization syndrome

Answer 489

Yes 1. initial management of open surgery e.g. while gaining haemodynamic control in unstable patient. Once cardiovascular stability improves (e.g., after controlling bleeding or gaining temporary aortic control), the procedure can be converted to GA to complete the surgery more safely. 2. Can also repair ruptured AAA by EVAR IMPROVE study found better outcomes/mortality if done under local however not all patients are anatomically suitable and may not tolerate

Answer 490

- back and abdominal pain can be severe and not tolerated - patient agitation from cerebral hypoperfusion can result in movement / non cooperative - use of aorto-uni-iliac graft and femoro-femoral cross over - respiratory insufficiency due to expanding retroperitoneal haematoma (aorto-uni-iliac graft as this requires femoro-femoral crossover graft which typically requires a groin-to-groin dissection, which is not well tolerated under local anaesthesia, hence general anaesthesia is required.)

Answer 491

- type 1 endoleak = failure to adequately seal proximal/ distal end of stent with the vessel wall and so ongoing bleed into the rupture - insidious bleeding from groin entry sites - endovascular arterial injury during guidewire / stent manipulation - failure to correct coagulopathy

Answer 492

- pre -existing renal disease - pre op hypotension / hypovolaemia - supra renal aortic clamp - intra op renal artery trauma - post op abdominal compartment syndrome

Answer 493

- A serious, life-threatening condition that occurs when intra-abdominal pressure (IAP) rises to sustained intra-abdominal pressure >20 mmHg that is associated with new organ dysfunction or failure. - Normal IAP is 12mmHg

Answer 494

o Residual retroperitoneal haematoma o Large volume fluid resuscitation o Electrolyte and metabolic disturbance o Ileus

Answer 495

As intra-abdominal pressure increases, it compresses: **o Abdominal organs** → impaired perfusion (e.g. kidneys, liver, bowel) - AKI, bowel ischaemia **o Diaphragm splinting** → restricted lung expansion → respiratory failure and increased airway pressures. **o Venous return** → compression of IVC and reduced cardiac output **o CNS** – increases intracranial pressure mainly through effects of cerebral venous drainage and hypercapnia from impaired ventilation

Answer 496

- Lower IAP through enemas, flatus, tubes - Prevent coughing, straining, ventilator dyssynchrony - Surgical decompression – open abdomen and cover with plastic membrane

Answer 497

Treat as major trauma - A with C spine protection, BCDE + manage immediate life threatening injuries Focused burns assessement - AMPLE history - time of injury, mechanism of burn - % coverage - lund and browder charts or wallace rule of nines - appearance - wet , dry , blisters - airway assessment for smoke inhalation injury secondary survery

Answer 498

estimation of % coverage based on body part burn Adults = 9% head, arms 9% each, legs 18% each, back 18%, chest 18%, perineum 1% children = same but head 18% and legs 13.5% each

Answer 499

by origin - chemical, thermal, electrical by thickness - superficial epidermal, superficial dermal (partial thickness), deep dermal (partial thickness) and full thickness

Answer 500

superficial epidermal - red, painful, dry, no blisters (epidermis only) superficial dermal (partial) - pink, blistered and red. includes epidermis and upper dermis deep dermal (partial) - dry, blotchy, red , painful = epidermis and lower/upper dermis full thickness = epidermis and dermis to sub cut = white , painless, no bleeding, dry, waxy

Answer 501

look for ... o Direct burns to face o Singeing of eyebrows and lashes o Swelling of the face, lips and tongue or oropharynx o Soot in nose, mouth or sputum Respiratory exam - o Coughing o Wheeze / stridor o sats

Answer 502

 Signs of severe CO poisoning  Signs of airway involvement / swelling * Stridor * Full thickness neck burns * Oropharyngeal oedema  Unconsciousness  Respiratory failure caused by lower airway issue from smoke inhalation leading to ARDS * Respiratory distress * Hypoxia / hypercapnia

Answer 503

size 8 = to fascilitate bronchoscopy un cut = to accomodate for airway swelling tape rather than tie due to facial swelling

Answer 504

parkland formula 4ml x kg x % surface area first half in 8 hours, second half in 16 hours hartmans or plasmalyte urinary catheter and guide IV fluids by urine output too.

Answer 505

for S.A > 15% below this can use oral hydration

Answer 506

- Urine output >0.5-1ml/kg/hr - Serum lactate - Haematocrit - Cardiac output monitoring or stroke volume variation monitoring

Answer 507

- Blood loss due to other injuries - Blood / evaporate loss due to debridement - Inhalation injury - Electric burns - Maintenance if no oral intake - SIRS response and further fluid shifts

Answer 508

- All burns >/= 2% TBSA in children or >/= 3% in adults - All full thickness burns - All circumferential burn – deep burn that completely encircles a body part e.g. Limb – risk of vascular compromise / compartment syndrome / ischaemia - Burns to hands, face, feet, genitalia, perineum - Any burn not healed in 2 weeks - Non accidental injury - - Any chemical , electrical or friction burn - Any cold burn

Answer 509

* Full thickness circumferential burns require escharotomy to prevent o compression of underlying vessels of limbs o Circumferential chest burns may impair ventilation * Surgical fasciotomies for compartment syndrome in unburned limbs due to accumulation of fluid from fluid resuscitation - * Burn wound debridement (An escharotomy is a surgical incision through non-compliant, full thickness burn tissue)

Answer 510

- Difficult IV access - Difficult monitoring e.g. arterial line and placing ECG stickers o May need to place skin staples instead of electrodes o Tongue / nose clips can be used in place of finger pulse ox - Chest burns may make ventilation difficult - Suxamethonium contraindicated 24hours after - May need blood products – oozing and long surgery - Analgesia is challenging

Answer 511

early - fluid overload, infection (VAP, burn wound, lines), DVT, GI ulcers, AKI, hypothermia late - pulmonary fibrosis, chronic pain, PTSD, sleep disorder , cosmetic

Answer 512

- Heat = burns of nasal and oropharyngeal mucosa cause swelling - Particulate matter deposition = soot settles in small airways causing mechanical obstruction, atelectasis and reduced compliance - Chemical irritants = inflammation of lung , oedema , V:Q mismatch - Systemic toxins o CO toxicity o Hydrogen cyanide – histotoxic hypoxia

Answer 513

- Symptoms = Voice change/ hoarseness , cough, burns to lips/ mouth/ pharynx - Signs = hypoxia, stridor, respiratory distress , soot in sputum / nose / mouth , crackles on chest consistent with pulmonary oedema

Answer 514

o Fire in enclosed space e.g. house fire o Delayed escape o Reports of Flames/ smoke/ steam o Loss of consciousness at the scene o Fatalities at the same incident

Answer 515

- ABG – hypoxia, raised carboxyhaemaglobin, lactic acidosis - CXR – may be normal but may show oedema / ARDS - VBG – difference in arteriovenous O2 DECREASED – due to inability to use O2 - Fibreoptic laryngoscopy – oedema , erythema and ulceration

Answer 516

bronchoscopy - diagnosis and grading of inhalation injury and to washout particulate matter lung protective ventilation nebulised heparin, salbutamol or 20% acetylcysteine chest physio

Answer 517

- Headache - Nausea - Weakness , dizziness - Confusion, convulsions

Answer 518

- High flow O2 prior to intubation - Continue to keep FiO2 1% - May require hyperbaric O2 (not recommended in inhalation injury)

Answer 519

- Hydroxycobalamin = binds cyanide to form non toxic product - Also sodium thiosulfate can be used

Answer 520

- Epidermis o Innate immunity / barrier function o Prevention of fluid loss o Melanocytes – skin pigmentation o Sensory function – light touch and pain - Dermis o Thermoregulation – dermal vascular plexus , piloerection, sweat glands

Answer 521

- Minimise patient exposure - Maintain theatre temp 28-33 degrees - IV fluid warmers - Forced air warmers - Use HME filter

Answer 522

- Surgical technique where an autologous tissue is completely detached from a remote donor site and transferred to recipient site - Circulation at the recipient site is restored by microvascular anastomoses usually of single artery and vein

Answer 523

- Local flap – tissue moved from an area very close to defect. types ... - o Rotational – tissue rotated around pivot point but remained attached to original site o Pedicle flap – tissue left attached at donor site but transferred up (no rotation)

Answer 524

- For wounds not suitable for primary / linear closure - Commonly used in reconstructive surgery e.g. o Trauma o Malignancy – reconstruction post mastectomy or H&N cancers o Facial reconstruction

Answer 525

- Flap elevation and clamping of vessels - Primary ischaemia as blood flow ceases and anaerobic metabolism - Reperfusion at anastomoses

Answer 526

- Appropriate patient selection o Contraindications include hypercoaguable states, sickle cell , polycythaemia - Smoking cessation – at least 4 weeks before o Improves nicotine induced vasoconstriction o Carbon monoxide related hypoxia o Hypercoagulable - Weight loss if appropriate

Answer 527

minimise primary ischaemia - mostly related to surgical time and technique. optimise flap reperfusion and minimise secondary ischaemia - O2 supply depends on O2 conc + flow * good arterial pressure but with low SVR * minimise venous pressures * normothermia - prevents vasoconstriction * good analgesia - prevents vasoconstriction * optimise viscosity - 30-35% optimise Hb

Answer 528

- Identifying flap failure / secondary ischaemia early - Clinical monitoring o Flap colour o Cap refil o Skin turgor o Skin temp o Bleeding on pin prick o Transcutaneous doppler - If signs of failure – early return to theatre

Answer 529

- Arterial supply = cool, pale, delayed cap refil, lack of bleeding on pin prick - Venous = warm, purple/ blue, swollen, venous bleeding on pin prick

Answer 530

- Insufficient Arterial supply – vasospasm, thrombosis , defective anastomoses, high SVR (vasopressors) - Insufficient Venous drainage – defective anastomoses , compression due to haematoma or oedema (excessive fluid, prolonged ischaemic time, excessive flap handling ) - Reperfusion injury to flap tissue o Microvascular failure from inflammatory mediators - Infection

Answer 531

- Risk of infection o Diabetes – poorly controlled o Chemotherapy / immunosuppression - Risk of thrombosis o Coagulopathies o Cancer o Polycythaemia - Reduced O2 supply o Anaemia o Smoker – vasoconstriction, tissue hypoxia , impaired oxygenation at lungs - Poor healing o Nutrition e.g. cancer patients

Answer 532

- Free flap is denervated and thus insensate - Also no direct sympathetic innervation - However donor site can be painful – regional / multimodel analgesia - Important to manage pain to prevent sympathetic response as this can lead to circulating factors that can affect flap perfusion can do standard methods of analgesia e.g. muscle from leg can do nerve blocks

Answer 533

- Pedicled flap o Latissimus dorsi flap - Free flap o Transverse rectus abdominis myocutaneous (TRAM) free flap – skin, fat and muscle o Superior and inferior gluteal flaps (IGAP, SGAP) – skin and fat o Transverse myocutaneous gracilis (TMG) flap – skin, fat, muscle

Answer 534

o Largest cranial nerve o Originates from pons – its brainstem nucleus lies here o Forms a single trigeminal nerve that carries info from the ganglion (gasserian ganglion) to the nucleus o Gasserien ganglion found in meckels cave in the middle cranial fossa. o The trigeminal ganglion contains cell bodies o From the ganglion 3 peripheral nerves arise - V1,2,3 - V1 - ophthalmic - enters via superior orbital tissue - - V2 - maxillary - Foramen rotundum - V3 - mandibular - Foramen ovale o Motor component originates in pons and joins v3

Answer 535

o sensation of face o Motor - muscle of mastication o Autonomic - lacrimal, nasal, parotid, submand, sublingual gland

Answer 536

o neuro vascular compression of the nerve root usually near its entry into the pons o usually involving superior cerebellar artery (but also basilar and anterior inferior cerebellar artery) o Results in distortion and atrophy of the nerve demyelination dysregulation of VG sodium channels o usually triggered by injury to the nerve or infection

Answer 537

o sharp stabbing pain o Unilateral o Intermittent o Lasting seconds to minutes (max 2 min) o In distribution of trigeminal nerve o Triggered by innocuous stimulus - light touch within trigeminal distribution E.g shaving, washing face, teeth brushing , chewing etc o Other symptoms - severe pain can cause facial spasms on ipsilateral side o Also can cause autonomic symptoms - rhinorrhoea , tears

Answer 538

V2/3 not usually opthalmic

Answer 539

o need to rule out serious causes o neurogenic causes: - Posterior fossa tumours - Masses within cavernous sinus - AV malformations and aneurysms - Multiple sclerosis - Cluster headache - Post herpetic neuralgia - Temporal arteritis o non neurogenic pain - dental abscess - parotid tumour - Salivary gland disorders - TMJ arthritis - Sinusitis

Answer 540

- Under 40yrs - FHx of MS - Hx of optic neuritis - History of skin or oral lesions that could spread perineurally - Bilateral pain - Ophthalmic region pain - Sensory changes /motor deficit - Absent blink reflex - Deafness (catagorise as patient demographics, FHx, PMHx, presenting features)

Answer 541

classical - more common, women > men, 50-60ys secondary - resulting from neurological disease or cerebllopontine tumours idiopathic - no secondary cause / nerve root compression

Answer 542

pharm - first line = carbemazepine - second line = gabapentin, pregabalin, lamotrigine , phenytoin, leveteracetam surgical - Microvascular decompression of trigeminal nerve in the posterior fossa - gamma knife stereotactic radiotherapy - ablation of nerve root / Gasserian ganglion - thermal , chemical, mechanical. - thermocoagulation

Answer 543

o Posterior fossa surgery o Requires GA o Physical untangling of neurovascular bundle at the nerve root to relieve it o Teflon felt is placed between the root and the nerves o Very effective - success of 90%

Answer 544

MSK - 95% nerve root pain -sciatica - 4% serious spinal pathology 1%

Answer 545

discogenic - arrises from afferent sensory nerve fibres within annulus fibrosus. due to degeneration of disc sacroiliac joint pain - low back and buttocks pain lumbar facet joint pain

Answer 546

- Sciatica is low back pain with radiation along distribution of sciatic nerve - - Hx o Radiculopathy usually worse than back pain o Sharp, shooting, electric shock like o Usually extends below the knee o May have paraesthesia o Worse with coughing/ sneezing - Exam o Positive straight leg raise o Sensory loss in affected dermatome o Muscle weakness in affected myotome o Depressed reflexes in affected myotome

Answer 547

- Compression of spinal nerve as it exists the spinal canal via intervertebral foramina o Disc herniation – usually younger patients o Osteophytes – usually older patients

Answer 548

- Demographic: o < 16 yrs or >50 yrs – new onset - PMHx: o Hx of significant trauma o Hx of malignancy / immunosuppression o Recent significant infection / TB - Symptoms o Constitutional symptoms – fever, weight loss, night sweats o Bladder / bowel dysfunction – incontinence / urine retention o Thoracic pain o Nocturnal back pain / severe persistent pain - Signs o Perianal paraesthesia o Reduced anal tone o Point tenderness over vertebral body / spine o Severe progressive neurological deficit in legs

Answer 549

- Aortic aneurysm - Tumours - Gynae pathology - Infection - Ankylosing spondylitis - Myeloma

Answer 550

- The cauda equina is a collection of spinal nerves (L2-5) leaving the spinal cord that remain in the dural sac. This occurs after L1 where the spinal cord ends - Cauda equina syndrome occurs if there is compression of these nerves e.g. by disc prolapse

Answer 551

- Severe lower back pain - Saddle paraesthesia - b/l leg weakness - bladder/ bowel dysfunction

Answer 552

- urgent MRI if suspected - neurosurgical emergency for decompression

Answer 553

o self-management/ patient education  information on the nature of back pain  continue activity – bed rest can worsen symptoms o graded exercise programme o physiotherapy o cognitive behavioural therapy o pain management programme – relaxation and exercise techniques and psychological

Answer 554

o NSAIDs/ paracetamol o Weak opioids (codeine / tramadol) only if NSAIDs contraindicated o Stronger opioids o Do not offer SSRIs, TCAs , gabapentin or other antiepileptics for lower back pain – no overall benefit (more for sciatica)

Answer 555

non surgical - radiofrequency denervation surgical decompression for sciatica

Answer 556

- Conservative and pharmacological options have not been effective - Main source of pain confirmed to be coming from structures supplied by the medial branch nerve / positive response to medial branch block - Moderate to severe levels of localised back pain

Answer 557

- These are psychological factors that are indicative of chronic and disabling back pain - o Negative attitude o Belief that back pain is harmful or severely disabling – fear and avoidance of activity o Depression / anxiety / social withdrawal o Expectation that passive rather than active treatment is beneficial o Social / financial problems o Over protective family / lack of support o Problems in other aspects of life e.g. work

Answer 558

If pain is accompanied by severe pain in the sciatic nerve territory

Answer 559

A neural plexus supplying upper abdominal organs the main junction of 3 sympathetic nerves - lesser , greater and least sphlanchnic nerves It is located near the coeliac trunk retroperitoneally at the level of L1. supplies gut up to tranverse colon, pancreas, liver, spleen, gall bladder and kidneys with autonomic supply and sensory nerve fibres. It coordinates gut activity and pain signalling

Answer 560

Greater splanchnic - T5-T9 lesser sphlanchnic - T10-11 least sphlanchnic = T12

Answer 561

pre ganglionic sympathetic fibres originate from spinal cord (in this case T5-T12) these fibres leave the ventral root and join white communicates to the sympathetic chain in this case the fibres do not synapse and instead bypass the sympathetic chain they travel to the coeliac ganglion (pre vertebral ganglia) post ganglionic fibres emerge from this ganglion to supply the abdominal organs. there are 3 pre ganglionic fibres forming coeliac plexus - greater, lesser, least sphlanchnic nerves

Answer 562

bilateral / paired structure Sits retroperitoneally Anterolaterally to L1 verebrae bilaterally anterior to vena cava and aorta (more medial to vena cava) sits either side of the origin of coeliac trunk either side of it sits the kidneys and in front of it sits the pancreas

Answer 563

- Cancer pain o Pancreatic cancer o Biliary tree cancer o Stomach cancer o Retroperitoneal organs - Chronic pain o pancreatitis

Answer 564

- Posterior - Anterior - Transaortic - Transdiscal - Paramedian

Answer 565

patient in prone position needle inserted at level of L1 , 5-10cm from midline angled at 45 degrees towards midline use fluroscopic guidance whilst needling inject constrast dye to confirm position before injecting phenol / local anaesthetic

Answer 566

**- Most common** o Diarrhoea - blocking sympathetic gut supply o Postural hypotension – due to blockage of sympathetic chain **anatomical** o Pneumothorax o Retroperitoneal haemorrhage – aortic or vena cava damage o Injury to kidney / panceas o Injury to artery of adamkiewicz and paraplegia e.g. phenol injection here – v rare o Direct spinal cord/ root damage o Intrathecal / epidural injection o Injection and abscess/ cyst of psoas muscle **Other** o Sexual dysfunction – phenol spread along sympathetic chain **General / non specific** o LA injection into great vessels o LAST o Allergy

Answer 567

Pain - CRPS, retractable angina, phantom limb pain, post herpetic neuralgia vascular insufficiency - raynauds, scleroderma

Answer 568

coagulopathy pathological bradycardia glaucoma (patient refusal, LAST, LA allergy)

Answer 569

- Formed by fusion of inferior cervical ganglion and 1st thoracic ganglion of the sympathetic chain - At level of C7

Answer 570

horners syndrome

Answer 571

between trachea and caortid sheath at level of C6 transverse process

Answer 572

- 4-10 - Ribs 1-3 are relatively protected by clavicle and shoulder girdle - Ribs 11 and 12 are floating so more mobile

Answer 573

- Pain causes o Reduced tidal volumes results in atelectasis, V:Q mismatch and shunting hence hypoxia o Also low tidal volumes may result in poor ventilation and high CO2 o poor cough and secretion retention o Results in pneumonia - Contusion injury to underlying lung – can cause.. o lung oedema, haemorrhage, necrosis o V:Q mismatching and hypoxia o ARDS

Answer 574

3 of more contiguous ribs fractured in 2 or more places such that a section of rib is separated from the thoracic cage

Answer 575

- Rib fracture scoring – old method - STUMBL – latest scoring method

Answer 576

- A clinical pain assessment to manage patients’ pain with rib fractures and can predict risk of complications / mortality - Age = +1 score for each decade over 10 yrs - Oxygen = +2 per 5% reduction in sats below 95% on room air - Fractures = +3 per fracture - +4 = if patient takes anticoag / anti platelet - +5 = if chronic lung disease - Total score o 1-10 = mild - Regular oral analgesia o 10-30 = moderate - PCA and regular adjuvants o >30 = severe - Regional anaesthesia

Answer 577

- Stepwise approach – starting point depending on rib fracture score o Step 1 oral analgesia = e.g. paracetamol, NSAIDS, weak opioids and oral morphine / oxycodone = rib fracture score of 15

Answer 578

thoracic epidural paravertebral block erector spinae plane block serratus anterior plane block intercostal nerve block

Answer 579

- Increased age - Increased number of rib fractures - Pre existing chronic lung condition - Anticoagulation - Lower O2 sats - (note this is STUMBL)

Answer 580

mid axillary line , 5th rib injection between serratus anterior and lattisimus dorsi patient can be supine

Answer 581

- No sympathetic block and low bleeding risk so can be used in those with coagulopathy - Easier to position patient for serratus anterior plane block – can do this supine

Answer 582

lateral cutaneous nerve - branch of intercostal nerve which originates from ventral ramus of the spinal nerve

Answer 583

no blockage of the dorsal ramus of the spinal nerve and thus doesnt cover posterior fractures limited if chest drain in place as uses same location for needling

Answer 584

trapezius and rhomboid

Answer 585

3cm from midline of the spine hits the transverse process of the vertebrae LA injected at this point

Answer 586

can be used with a chest drain (different location for needling) better for posterior fractures - dorsal rami also blocked

Answer 587

- better in anticoagulated patients - Avoids unnecessary bilateral block if theres only rib fractures on one side. - Less sympathetic block and hypotension / bradycardia - Less risk of infection , bleeding, neuraxial haematoma

Answer 588

- Surgery o Thoracic surgery o Breast surgery - Trauma o Rib fractures o Liver capsular pain from blunt trauma - Chronic pain o Post herpetic neuralgia o Neuropathic chest / abdo pain

Answer 589

- Absolute- Local sepsis , LA allergy , Patient refusal or Structural abnormality in the space e.g. tumour - Relative - coagulopathy, respiratory compromise, scoliosis

Answer 590

less sympathetic blockage uses USS whereas epidural is a blind proceedure higher successrate lower incidence of neuro complications fewer complications overall e.g. urinary retention

Answer 591

- Hypotension – blocking sympathetic chain - Vascular puncture – intercostal vessels - Pleural puncture – pneumothorax - Epidural spread – bilaterally blockage and side effects associated with epidurals - Ipsilateral Horner’s – in high blocks due to sympathetic chain blocked

Answer 592

bilateral fractures or higher level rib #

Answer 593

most significant sympathetic blockade compared to other regional options - hypotension / bradycardia contraindicated in coagulopathy, spinal fracture, spinal cord injury difficult to position patient for insertion

Answer 594

nociceptive pain - infection, wound dehiscence, haematoma etc medication related - wearing off regional anaesthesia OR inadequate pain relief prescribed / tolerance developing equiptment related - failure of PCA (occlusion or empty syringe) / tissued cannula other traumatic injury phantom limb pain - neuropathic

Answer 595

**- PERIPHERAL NS:** o The preceding limb trauma may have damaged peripheral nerves o This can lead to sensitisation = Upregulation of Na/ Ca channels – spontaneous/ectopic firing at the stump or in the dorsal root ganglion o Neuromas can develop in damaged nerves that are sensitive to mechanical and chemical stimulus. o Trauma/ Surgery then releases inflammatory cytokines / mediators e.g. substance P / prostaglandins to further sensitise the nerves peripherally **- CENTRAL NS** o Within the spinal cord there is intense nociceptive inputs from peripheral NS which can result in central sensitisation – involving NMDA receptors o Now allodynia and pain is felt beyond the normal dermatomal distribution **- SOMATOSENSORY CORTEX:** o After amputation there is also cortical remapping in the somatosensory cortex o brain area that once processed the amputated limb's input gets taken over by neighboring areas (e.g., face or trunk). o mismatch between the brain’s "map" and actual body leads to misinterpretation of signals as pain.

Answer 596

- Pain character – cramping, burning, shooting , aching - Commonly experienced in distal part of amputated limb i.e. distal to stump - Degree of pain – disproportion between pain experienced and stimulus applied - Other non-painful sensory phenomena = itching and tingling - Very common following amputation - Mostly develops within first week post op

Answer 597

- Severe pre op pain - Lower limb amputation - Bilateral amputation - Presence of severe nociceptive stump pain - Increasing age - Revision surgery

Answer 598

o Regular paracetamol / NSAIDs o Morphine IV – titrated to effect o Gabapentinoids– possibly prophylactic effect too if taken pre op o Ketamine IV o Local anaesthetic techniques – IV lidocaine, lidocaine patch over stump, indwelling peripheral nerve catheter (sciatic nerve block or catheter ) or Epidural analgesia

Answer 599

o Pharmacological – oral - Amitriptyline , Duloxetine / venlafaxine , Gabapentin / pregabalin o Pharmacological – non oral - given if above first line methods have failed. = Capsaicin 8% patch , Lidocaine 5% patch , Botulinum toxin A o Other: Mirror therapy , TENS, CBT or Implanted spinal cord stimulator

Answer 600

- Implanted device which is used to treat chronic pain of neuropathic origin - Consists of single or multiple electrodes placed in the dorsal epidural space - Connected to an implantable pulse generator placed subcutaneously - This sets a pattern of stimulation to the electrodes

Answer 601

- Electrically stimulates the dorsal column , lateral funiculus and dorsal roots - Inhibits afferent nociceptive pathways - Activates descending inhibition - Supresses efferent sympathetic fibres - Overall they achieve their effect through the gate control theory and modulation of release of other neurotransmitters

Answer 602

neuropathic pain CRPS ischaemic pain - angina or PVD post amputation pain diabetic neuropathy

Answer 603

**PRE OP** - Seak advice from the team that manages the patient SCS **INTRA OP** - SCS turned off in surgery to avoid accidental reprogramming or activation by electromagnetic interference - Careful when positioning patient – pressure area implications/ rotation could result in lead migration - Avoid neuraxial techniques due to risk of damage to leads or infection = Thoracic epidurals are absolutely contraindicated, - Bipolar diathermy used when possible. If monopolar is required, place the plate as far from SCS as possible **POST OP** – device switched back on and checked by pain team (If neuraxial techniques are essential – should be undertaken under specialist supervision, fluoroscopic guidance and strict asepsis)

Answer 604

- Opioid receptors are located within the rexed’s laminae I and II of the dorsal horn presynaptically on C and Ad fibres - Stimulation causes inactivation of VG Ca channels OR K+ channels to open. - Overall less neurotransmitter release – glutamate and substance P - Opioid receptors are also located post synaptically where their activation causes potassium channel opening and indirect activation of descending inhibition pathways from the brainstem

Answer 605

- Intrathecal opioids will spread in the cephalad direction (upwards) - Opioid receptors in the nucleus raphe magnus & periaqueductal grey & locus coeruleus, thalamus and cortex - Results in reduced GABA inhibition of the descending pathways - Hence more descending inhibition of pain transmission

Answer 606

- N&V - Respiratory depression - Pruritis – more common than systemic - Sedation - Delayed gastric emptying - Urinary retention – more common than systemic - Sweating Most side effects are more common with systemic opioids as higher doses typically needed for same effect

Answer 607

**- Patient factors** o Increasing age o Hx of Sleep apnoea or obesity hypoventilation syndrome o Coexisting respiratory disease **- Opioid used:** o Use of hydrophilic opioids e.g. morphine – **- Aesthetic factors** o Concurrent use with other sedative medications Lipophilic opioids will rapidly diffuse out into fatty tissue, plasma concs will peak early and any resp depression will occur early Hydrophilic remain in CSF for longer and peak plasma conc and resp depression occur later

Answer 608

- ITDD systems deliver drugs to CSF - e.g. opioids, LA, clonidine, baclofen - The pump may be fixed externally or fully implanted with reservoir filling performed percutaneously - may have a fixed rate or be programmable – this can be affected by MRI - may be sited anywhere from thoracic to sacrum

Answer 609

- Dural granuloma formation - Leg oedema - Infection - CSF leakage - Drug error - Pump or catheter problem e.g. occlusion

Answer 610

- Should only be used by experienced clinician - Spinal anaesthesia o Risk of infection so only use spinal anaesthesia if benefits outweigh risks o Avoid area of the device o Intrathecal bolus can be given VIA the device if at appropriate level - Meticulous aseptic technique when using the system to avoid infection - No diathermy within 30cm of pump / catheter

Answer 611

**- Local mass effects of the tumour / tumour invasion** o Inflammation, compression, oedema and ischaemia of neighbouring tissues , visceral stretch, bowel obstruction **- Peripheral sensitisation** o e.g. tumour or immune system releases prostaglandins, leukotrienes etc that sensitise nerve endings to pain **- paraneoplastic phenomena** peripheral neuropathy or mononeuritis **- Cancer treatment** o Post surgical pain – e.g. massectomy or thoracotomy o Radiation induced neuritis following radiotherapy o Peripheral neuropathy following chemotherapy **- Due to related problems** o Hypercalcaemia causing abdo pain o Pathological fractures - Psychological factors due to cancer and pain and pre-existing psych conditions

Answer 612

- WHO analgesic ladder should be used - Consider adjuvants o E.g. for neuropathic pain o steroids to reduce inflammation o bisphosphonates for bony pain - When prescribing opioids o Long acting background opioids used alongside short acting for breakthrough pain ( 1/6th the dose of 24 hour dose )

Answer 613

steroids reduce inflammation and oedema associated with tumour growth e.g. liver capsule pain, bony mets bisphosphonates - inhibit osteoclasts and hence bone resorption so good for bony pain

Answer 614

- Minimise opioid use by using adjuvant therapies e.g. multimodal analgesia, psychotherapy, interventional therapy - Manage specific side effects – laxatives, antiemetics - Give naloxone for more serious side effects - Lowest possible dose and convert to long-acting preparations to reduce addiction Opioid rotation

Answer 615

- **WHO ladder**– paracetamol / NSAIDs - **Treat neuropathic pain** with other agents – TCA, gabapentinoids - **Other adjuvant therapies** – ketamine, cannabinoids - **Treat underlying causes of pain** - Hyoscine butylbromide (buscopan) , Bisphosphonates for bone pain , Steroids for spinal cord compression / liver capsule pain - **Interventional procedures** - Coeliac plexus block ( LA or steroid or phenol), Epidural or intrathecal analgesia , or Neurolytic procedures (chemical ablation) -**Reduce tumour size with oncology treatment** - Chemo / hormone / immunotherapy - **Manage associated psychological conditions** – depression / anxiety - SSRIs remember this Q is pharmacology only

Answer 616

- Surgery – fixation of pathological fractures, defunctioning ileostomy to relieve bowel obstruction - Radiotherapy – reduce tumour size and mass effects - Physical therapy / graded exercise programme / physiotherapy - Psychological – CBT - Other – acupuncture , aromatherapy

Answer 617

- Chronic pain syndromes – due to persistent cancer related pain - Opioid tolerance - Psychological factors – from cancer or pre-existing – depression / anxiety

Answer 618

- Compression of nerve - Chemotherapy induced neuropathy - Radiation induced nerve damage - Surgical nerve injury - Paraneoplastic syndromes

Answer 619

- CBT - Mindfulness based stress reduction - Support groups

Answer 620

pain that develops or increases in intensity after a surgical proceedure, persisting for more than 3 months and cannot be explained by other causes e.g. infection or reoccurance of underlying condition it is also localised to the surgical area can be neuropathic, nociceptive or mixed

Answer 621

- Amputation , Knee arthroscopy, - Knee / hip arthroplasty - Thoracotomy , Mastectomy , Sternotomy - Craniotomy - Inguinal hernia repair , Laparotomies , C section

Answer 622

- Younger age - High BMI - Female sex - Psychological factors – anxiety, fear of surgery, depression - Genetic susceptibility - Lower educational level - Poor social support / unemployment - Pre op pain / other chronic pain condition e.g. fibromyalgia - Smoking

Answer 623

- Procedures involving significant nerve / tissue damage - Longer duration of surgery - Surgical complications - Repeated surgery - Adjuvant radio therapy - Adjuvant chemotherapy which is neurotoxic - Poor post op pain control

Answer 624

2 main ones - Use of regional anaesthesia - Reduced opioid use by focusing on multimodal analgesia other points - TIVA vs inhalation= high dose remi increases incidence.However TIVA with low dose remi less incidence than inhalation (other agents including ketamine , magnesium, clonidine, NSAIDS have been studied and may be useful but above 2 are more evidence based)

Answer 625

**PERIPHERAL** - Surgery causes neuronal damage =Upregulation of VG Na channels – ectopic firing - Surgery and local inflammation causes release of cytokines / inflammatory mediators = Peripheral sensitisation of nociceptive receptors, spread of hyperalgesia zone to increase receptive field , Microglial activation **CENTRAL** - Increased signals received from peripheral NS – increased glutamate release at dorsal horn - NMDA receptor activation and neuromodulation - Results in allodynia and hyperalgesia and increased receptor field - Also modulation of the descending inhibition

Answer 626

pre op - review regular opioids route, dose and reason. continue these usually. Involve the chronic pain team to optimise. formulate a post op plan intra op - differing opinions whether to cont or stop buprenorphine patches - use multimodel analgesia - use nerve blocks/ regional - can use additional opioids post op - PCA with higher dose of bolus - needs careful monitoring - pain team review - pain assessment - scores

Answer 627

- Partial agonist of MOP - Antagonist of KOP and DOP - High affinity so prolonged duration of action - Continuing buprenorphine may reduce the max effect of other opioids administered perioperatively and cause analgesic failure

Answer 628

- Rotate to full agonist well in advance of surgery - Ensure max opioid sparing analgesia given - If continuing buprenorphine, give max other opioid periop OR supplemental buprenorphine

Answer 629

- Transdermal absorption perioperatively may not be reliable e.g. if patch is warmed under forced air warmer then absorption increased OR if peripherally shut down, decreased - Buprenorphine is a partial agonist and thus may complicate the dosing of full agonists e.g. morphine and fentanyl - reduces max effect of full agonist

Answer 630

- NSAIDs/ paracetamol - Regional anaesthesia – block or catheter - Neuraxial anaesthesia - Ketamine - Gabapentin - Lidocaine infusion - Magnesium infusion - Clonidine

Answer 631

an unpleasant sensory and emotional experience associated with actual or potential tissue damage

Answer 632

- Acute or chronic - By type o Nociceptive o Neuropathic o Visceral

Answer 633

acute = noxious signalling from recently damaged tissues, < 3 months chronic = pain that persists for > 3 months, beyond expected period of healing and serving no protective function. can be nociceptive/ neuropathic

Answer 634

- Chronic primary pain = Characterised by emotional distress / disability not better accounted for by other cause of chronic pain - Chronic cancer pain - Chronic post surgical pain - Chronic neuropathic pain - Chronic secondary headache / orofacial pain - Chronic secondary visceral pain - Chronic secondary MSK pain

Answer 635

- History - SOCRATES o Site, onset, character, radiation, associated features, timing, exacerbating / relieving factors , severity - Physical examination o Observations o Examination of wound / relevant area o Pain scoring tools – numerical scale, visual analogue scale , facial fain scale (paeds), verbal rating scale (mild, moderate, severe) - Review anaesthetic chart / analgesia received so far

Answer 636

- Pain history - SOCRATES , How the pain started - Psychological impact- Mood , Sleep , Physical function , Work and social life - Treatments tried so far - Patients concerns / ideas / expectations - Physical examination - General examination , Neurological exam , MSK exam - Ix = CT / MRI may be indicated , Chronic pain assessment tools

Answer 637

- These are multidimensional tools that assess the intensity of pain, nature of pain and impact on mood etc - E.g. McGill Pain Questionaire (MPQ) = 20 items assessed - E.g. Neuropathic pain scale (NPS) = 10 items - E.g. brief pain inventory

Answer 638

- Aids treatment of pain in stepwise approach - Step 1 = paracetamol / NSAIDs - Step 2 = weak opioid - Step 3 = strong opioids

Answer 639

- Respiratory depression - Constipation - Itching - Nausea and vomiting - Delirium / confusion - Sedation , low GCS - Pin point pupils - Tolerance and addiction - Immunosuppression – chronic opioid use can modulate immunity

Answer 640

- Adrenergic hyperactivity – tachycardia, palpitations, sweating, hypertension, hyperthermia , shivering - Generalised malaise – flu like symptoms , myalgia - Abdominal cramps, diarrhoea , N&V - Lacrimation and rhinorrhoea - Yawning

Answer 641

- tolerance – need higher doses for same effect - dependence – physical reliance - side effects - immune modulation – infection risk - opioid induced hyperalgesia – increased sensitivity to pain regularly assess pain and titrate to lowest effective dose, opioid rotation and multimodel analgesia

Answer 642

- Genetics plays a crucial role in individual variability in o pain perception o susceptibility to chronic pain conditions o response to analgesic treatments. - Understanding genetic influences can aid in personalized pain management strategies. e.g. differences in neurotransmitter systems (receptors, levels of NT release), differences in inflammatory responses and hence whether chronic pain develops and pain sensitivity

Answer 643

**- Pharmacokinetics** o Adsorption differences o Distrubtuion – plasma proteins, fat distrubtion etc o Metabolism – polymorphisms in CYP450 system- CYP2D6 varients poorly metabolise codeine and have inadequate analgesia o Excretion – efficacy of kidney function **- Pharmacodynamics** o Polymorphisms in receptors and downstream pathways

Answer 644

- SCN9A is a gene encoding the Nav1.7 VG Na channel - This channel is critical for nociceptive neuron excitability - It can be mutated resulting in deficiency and insensitivity to pain OR gain of function and increased pain.

Answer 645

- The study of how genetic variation affects drug response

Answer 646

- Depression and anxiety - Sleep disturbances - Substance missuse - Social isolated - Uncontrolled severe pain - Poor coping mechanism

Answer 647

- Patient health Questionaire 9 – PHQ 9 - Columbia -suicide severity rating scale (C-SSRS)

Answer 648

- Recognise depression and suicidal ideation - Initiate conversations about mental health - Coordinate with mental health professionals - Optimise pain management - Educate patients in interplay between pain and mood

Answer 649

- Early identification and treatment of mood disorders - Patient education on pain and coping strategies - Enhancing access to mental health services - Promoting social engagement and support - Regularly reviewing pain management efficacy

Answer 650

pain that arises as a consequence of a lesion / disease affecting the somatosensory system characterised by shooting, burning, electric shock like pain.

Answer 651

spontaneous episodes of pain - Character o Shooting, burning, electric shock, o Paraesthesia = tingling - Allodynia – non noxious stimulus - Hyperalgesia/ hypoalgesia – increased / decreased severity

Answer 652

- Central o Spinal cord injury o MS o Post stroke - Peripheral o Diabetic neuropathy , B12 deficiency, alcohol excess o Post herpetic neuralgia o Trigeminal neuralgia o Phantom limb pain o Infections – HIV and syphilis o Autoimmune – SLE, RA

Answer 653

- Longer duration of diabetes - Poor glycaemic control - Hypertension - Smoking - Hyperlipidaemia - High BMI

Answer 654

- Hyperglycaemia – damage to microvascular supply to nerves resulting in nerve damage - Hyperglycaemia causes inflammation and hence damage to nerve endings

Answer 655

* Neuropathic pain is poorly managed. Combination therapy is better than mono therapy * NICE GUIDELINES: o First line (except trigeminal neuralgia)  amitriptyline, duloxetine, pregabalin, gabapentin o second line  Add in a second agent from the above list other pharm... o Tramadol for acute rescue therapy only o Consider capsaicin cream * Chronic neuropathic pain = medical treatment is coupled with psychological input to produce the holistic approach * Interventional treatments o Peripheral nerve blocks / steroid injections o Dorsal root entry zone ablation treatments o Deep brain stimulation

Answer 656

- Oral medications not tolerated and pain well localised

Answer 657

- TRPV1 receptor agonist – a type of Ca channel - Present in C fibres - Causes initial stimulation and release of substance P but then subsequent depletion and reduction in substance P over time

Answer 658

* adverse effects of medications * Abuse potential for some of the meds * Complex interplay between pain and psychological factors * Lack of familiarity of some meds by GP / medical staff

Answer 659

- Transversus abdominus plane (TAP) block - Rectus sheath catheters - Thoracic epidural - Quadratus lumborum blocks - Spinal catheter / single shot spinal

Answer 660

- Pain disorder characterised by limb pain accompanied by sensory, vasomotor, sudomotor and trophic changes - Precipitated by trauma or surgery

Answer 661

- Type 1 o Reflex sympathetic dystrophy o Associated with injury to tissue but no nerve injury o Usually precipitated by ortho injury to distal extremity - Type 2 o a.k.a causalgia o characterised by significant nerve injury without transection

Answer 662

- Clinical diagnosis - Budapest criteria uses the above symptoms/ signs to diagnose CRPS - To make diagnosis the following criteria must be met: o Continuing pain disproportionate to inciting event o No other diagnosis can better explain the presentation o At least 1 symptoms in 3 or more of the categories above o Atleast 1 sign in 2 or more of the categories

Answer 663

- Vitamin C 500mg OD for 50 days after wrist fractures have been shown to reduce development - Early rehabilitation after trauma

Answer 664

- MDT approach **- Conservative:** o Patient education o Physiotherapy / physical rehabilitation – restore/ maintain limb function -Fine motor exercises , Mirror visual feedback , Gradual weight bearing o Psychological – CBT o Occupation therapy **- Medical therapies – weak evidence** o Simple analgesia , TCA, Gabapentinoids, SNRIs – duloxetine , capsaicin cream, lidocaine patch, Vasodilators – CaCB **- Interventional techniques** o Spinal cord stimulator o Dorsal ganglion stimulator o Intrathecal baclofen for dystonia o IV regional sympathetic blocks

Answer 665

- GA o Useful for prolonged procedure , allows transoesophageal echo to assess rare complications , less movement improves accuracy of mapping - Sedation with LA o Useful to avoid supressing arrhythmia and thus success can be identified

Answer 666

- Advantages o No need to transfer unstable patient o Minimises delays to treatment o Close availability to cardiology specialist equipment, drugs , staff o Don’t delay emergency list in theatres - Disadvantages o Remote anaesthesia – unfamiliar environment o Potential lack of monitoring e.g. capnography o Lack of access to full range of anaesthetic drugs and equipment o Fewer skilled anaesthetic staff e.g. ODP / other anaesthetist – so less timely support in times of emergencies o Risk of forgetting / lack of compliance with WHO checklist o Less equipped recovery facilities

Answer 667

- Fasting status - Patient cooperation / preference - Presence of reflux - Anticipated difficult airway - Post cardioversion plans e.g. transferring elsewhere to cath lab for another procedure. - Medical hx and allergy status

Answer 668

ANAESHETHIC RELATED: - Aspiration - Cardiovascular instability due to anaesthetic agents and arrhythmias - Risk of awareness NON ANAESTHETIC - Arterial embolization causing stroke - Asystole / PEA/ VF - Burns - Electrical injury to staff

Answer 669

- Electrical shock delivered to cerebral hemispheres to induce a grand mal convulsion for specific duration (15-120 seconds) - Used in the treatment of psychiatric disorders such as severe depression

Answer 670

Severe medication resistant depression – especially associated with psychomotor retardation, mania, catatonia, psychosis and schizophrenia

Answer 671

- 30-45 joules of energy for 1-1.5 seconds - The aim is to produce a tonic clonic seizure lasting between 15-120 seconds - - Unilateral electrode placement o Both electrodes on the non-dominant hemisphere o minimises cognitive side effects o Less clinically effective - bilateral electrode placement o Electrodes are placed on both sides o Most effective for clinical improvement - Repeat twice a wek for up to 12 treatments

Answer 672

- Cardiovascular effects o Initial parasympathetic discharge – bradycardia, occasional asystole o Then followed by sympathetic discharge – tachycardia, HTN, sweating, lacrimation, increased myocardial O2 consumption and risk of ischaemia o Risk of post procedure myocardial stunning with reduced ejection fraction – risk of heart failure - Airway o Risk of laryngospasm o Increased salivation – parasympathetic o Risk of aspiration - Cerebral o Increased cerebral O2 requirments o Increased ICP o Risk of haemorrhage o Risk of TIA o Risk of status epilepticus o Reduced cognitive function after – memory loss, concentration, disorientation - MSK o Injuries o Increased lactic acid release o Myalgia - GI o Increased gastric pressure and hence reflux

Answer 673

- Dental damage – due to seizure plus bite block - Intra oral damage – biting - MSK – fractures - Myalgia due to seizure or use of suxamethonium

Answer 674

- Raised ICP / space occupying lesion - Recent stroke - Unprotected cerebral aneurysm - Recent MI within 3 months or unstable angina - Uncontrolled HF - Severe systemic HTN - Unable spinal fracture or severe osteoporosis

Answer 675

A: - difficult airway/ aspiration risk - significant reflux (as unlikely to tube), and dentition as bite block is used C: - rule out significant contraindication e.g. significant IHD or HF or raised ICP or untreated cerebral aneurysm , recent cerebrovascular event - pace makers and ICDs inactivated / assynchronous mode D: - Capacity for consent – patient may be under section - Psychiatric illness may make it difficult to conduct a proper pre op assessment , unknown compliance to medications and fasting rules E: - Remote site anaesthesia considerations – ensure full staff, monitoring, drugs, recovery fascilities are available - Current medications – lithium can exacerbate NMBA , MOAI – hypertensive crisis

Answer 676

- IV access, AABGI , trained assistant , airway equipment available and emergency drugs and resuscitation equipment - Anaesthesia provided by consultant or experienced SAS anaesthetist - Induction - propofol ,Suxamethonium - Bite guard introduced - O2 via facemask / ventilated to induce hypocapnia ( reduces seizure threshold) - Atropine / glycopyronium may be needed – parasympathetic activation by ECT and use of sux - Have benzo’s ready if seizure lasts more than 2 mins

Answer 677

- Potentiates NMBA - Possible reduction in anaesthetic dose requirements due to reduction in brainstem catecholamine release - Renal excretion – NSAIDs reduce its elimination and can result in toxicity - Risk of nephrogenic diabetes insipidus - Narrow therapeutic index – risk of toxicity, check levels - Risk of serotonin syndrome – care when giving other serotonin drugs e.g. tramadol, fentanyl, ondansetron - Omit for 24 hours prior to anaesthesia for major surgery

Answer 678

- Risk of serotonin syndrome - Inhibits CYP2D6 – codeine and tramadol metabolism - Co-administrating NSAIDs – increases bleeding risk, both impact platelet activity

Answer 679

- This is the area within which there is risk of projectile damage, heating and risk to implanted devices - 5 Gauss - A.k.a the 5 gauss line

Answer 680

**Advantages of the MRI** - Non ionising - Good for soft tissue - High resolution **Disadvantages of an MRI ** - Long scan duration - Claustrophobic and noisy - Large magnet can be dangerous and special monitoring equipment needed - Expensive

Answer 681

- Ventilated ICU patient - During surgical proceedute e.g. neurosurgery - Patients with movement disorders - Uncooperative – children, learning disabilities , anxiety

Answer 682

- Remote anaesthesia o Unfamiliar environment o Lack of trained anaesthetic staff o Special MR safe equipment o Lack of access to patient - Static magnetic field o Projectiles of ferromagnetic material e.g. O2 cylinders o Ferromagnetic objects in the eye e.g. shrapnel – may be disloged – vitrous haemorrhage o Pacemakers inactivated / reprogrammed - Induction of currents - Acoustic noise – ear protection required - - Radiofrequency heating o Burns through conductive material e.g. ECG leads / metal in clothing - Helium escape o Hypoxic environment

Answer 683

- MR safe – devices that pose no MR related hazards to patients or staff when used according to instructions - MR conditional – equipment that is safe to use in MR under specific conditions e.g. below certain magnetic field strength - MR unsafe = hazardous in MR environment and can not be used

Answer 684

- Recent surgery involving ferromagnetic clips or implants e.g. neurosurgical clips or cochlear implants - Intra-arotci balloon pumps , ventricular assist devices - Neurostimulators - Implantable cardiac devices - Programmable shunts for hydrocephalus - Orthopaedic implants

Answer 685

anterior - femoral, obturator, accessory obturator posterior - sciatic, nerve to quadratus femoris and superior and inferior gluteal nerves

Answer 686

- femoral nerve block - fascia iliaca compartment block - 3 in 1 block - Pericapsular nerve group block (PENG) - Quadratus lumborum block - Erector spinae block

Answer 687

- Reduce periop pain - Reduces need for systemic opioids and adverse effects - Early mobilisation – less DVT / pneumonia - Increases chance of day case for THR

Answer 688

- Anterior = posterior surface of the fascia ilica - Posterior = anterior surface of the iliacus and psoas muscle - Medially = origin of psoas major and vertebral column which it originates - Laterally = origin of iliacus muscle along the iliac crest

Answer 689

- Femoral - Lateral cutaneous nerve of the thigh - Obturator

Answer 690

- Posterior hip capsule and the ischiocapsular ligaments is from the sciatic plexus

Answer 691

- Safe due to injection site remote from major vessels / nerves - Can be safely performed with landmark or USS - More of a complete block - covers lateral cutaneous nerve of the thigh ( incisional pain) and obturator nerve - Reduces opioid use and improves pain control

Answer 692

- Suprainguinal - Infrainguinal

Answer 693

- Femoral artery / vein puncture with risk of vascular injection and risk of LAST, pseudoaneurysm formation or haematoma - Femoral nerve block can cause quadriceps weakness or femoral nerve damage - Super inguinal technique - Risk of bladder puncture, Risk of peritoneal puncture - High volume required as it’s a compartment block – hence risk of toxicity

Answer 694

- Pre op pain management – to facilitate xray / patient comfort - Intra op – multimodel alagesia – opioid sparing - Mainly for hip surgery but also for knee

Answer 695

pericapsular nerve group block targets articular branches of the femoral and obturator nerve (and accessory obturator nerve) These are found in the facial layer between psoas tendon and ilium MOTOR sparing - good for day case THR Still provides pain relief and reduces opioid use

Answer 696

- Complication of any surgery involving cement which results in varying levels of hypoxaemia and hypotension - Not entirely clear on the aitiology. May be due to anaphylactoid reaction to cement or embolic phenomena whereby cement / fat / bone particles enter the circulation

Answer 697

- Patient factors o ASA 3 or 4 o Pre-existing cardiac disease o Pre-existing pulmonary HTN o Osteoporosis o Male o Diuretic treatment o Increasing age - Surgical o Pathological fracture o Intertrochanteric fracture o Long stem arthroplasty

Answer 698

- Closed loop communication to make team aware of cementing process - - Cementing technique o avoiding excessive pressurisation o Wash and dry femoral canal o Apply cement in retrograde fashion using gun with suction catheter and intramedullary plug in femoral shaft - Avoid use of cement where surgically appropriate - Good hydration and BP by anaesthetist – BP within 20% of induction - - Treat CVS collapse promptly – vigilance o Invasive BP monitoring if high risk patient o Close eye on EtCO2 and BP o Have vasopressors prepared

Answer 699

- Regular paracetmol - Opioids if required but limit these and minimise long acting - NSAIDs not recommended - Regional

Answer 700

- No evidence of superior technique e.g. spinal vs GA * Avoid hypotension – MAP >80mmHg – increased mortality found if < 80 for >10mins. Worse cognition in elderly , Worse for bone cement syndrome * Minimise risk of post op cognitive dysfunction o Avoid excess opiates o Avoid long acting sedatives e.g. misazolam o Avoid cholinergics o Avoid long periods of hypotension - Avoid excessive depth of anaesthesia o Use BIS or age adjusted MAC - Regional o Alongside spinal / GA

Answer 701

- Surgery within 36 hours of admission on a planned trauma list with consultant or senior staff supervision - Geriatrician review within 72 hours of admission - Pre op cognitive test – Abbreviated mental test (AMT) - Assessment for bone protection, falls and nutrition - Post op delirium assessment – 4 A’s test (4AT) - Post op physiotherapy assessment – no later than 1 day after surgery

Answer 702

- Airway = Access to airway is suboptimal - Ventilation = Reduced FRC , Some V:Q mismatch may occur – - Neurological - Peripheral nerves  radial in lower arm  common peroneal in lower leg  saphenous nerve (have pillow between legs  brachial plexus – if poorly positioned axillary roll or neck not in neutral positon o eye injury – lower eye higher ocular pressure o macroglossia if excessive neck rotation / neck flexion – occluding IJV o folded lower ear – pressure necrosis

Answer 703

- Advanced age - Male - Reduced cognitive function - Anaemia - Two or more active co-morbidities - Active malignancy within the last 20 years - Institutional living prior to admission

Answer 704

- Only need to wait 24 hours since last dose for spinal anaesthesia (normally 48hours however risk vs benefit) – assuming normal renal function

Answer 705

- Prehabilitation o Education and management of patient expections - Life style modification o Smoking cessation – 4 weeks pre op o Alcohol cessation - Anaemia management o Identification and treatment o Oral or IV iron reduces need for transfusion o Managing preoperative anaemia reduces post operative complications and may avoid the need for perioperative blood transfusion. - Reduced pre op fasting o Sip to send o Carbohydrate drink o Supports post op recovery

Answer 706

- NA is linked to fewer complications than GA (however can cause urinary retention) o Lower mortality, pneumonia, AKI, DVT/PE, stroke and MI risk o High risk of urinary retention - NA reduces surgical stress response and improves outcomes

Answer 707

- Motor-sparing regional anaesthesia - PENG block, lumbar erector spinae plane block or quadratus lumborum - local infiltration analgesia (LIA) - A multimodal analgesic (MMA)

Answer 708

Chamber paced, chamber sensed , response to pacing Common modes - VVI - ventricles paced , ventricles sensed and if electrical activity sensed the pacemaker is inhibited - VOO - ventricles paced, no sensing - this is a asynchronous mode - used in emergency / switch to this in theatre if pacemaker dependant

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